Application Form for the
4th Baltic Sea Summer School on Epilepsy

June 6-11, 2010, Granavollen, Norway

Application deadline is April 10, 2010

Priority deadline for applications from the Baltic Sea region is February 1st, 2010

* denotes mandatory data
First name*:
Last name*:
Year of birth*:
Gender*:	Female      Male
Contact address*:
Country*:
E-mail*:
Home Telephone:
Work Telephone*:
Fax:
Work place / Institution*:
Job title*:
Specialty/degree*:	Obtained in year*:
Title of case report*:
Another possible title*:
Video case report*:	Yes      No
Please note that only one CEA or ILAE bursary per year is possible per person.
Do you wish to apply for financial support (bursary)*:		Yes      No Please note that, in case of a bursary request, you agree that your name will be saved in an ILAE database accessible to ILAE course organizers only.
If you apply for financial support, please justify your request:
Are you able to participate without this financial support:		Yes      No
I confirm that I have not been granted another bursary from the CEA or ILAE for the year 2010*:		Yes      No
I have applied for another bursary from the CEA or ILAE in the year 2010*:		Yes      No If yes, for what course(s):
I confirm that all information provided by me is truthful* This form will be sent to ruta.mameniskiene@yahoo.com and petra@epilepsy-academy.org.

Please note that only applications received within deadline limits and with all necessary attachments can be considered and please make sure that you keep us updated of any changes in your application.

Applicants will be informed of the outcome of their application as soon as possible.