Online Application for
VIREPA Distance Education Courses

* denotes mandatory data
 
Course for which you apply*:
First name*:
Last name*:
Year of birth*:
Gender*:  Female      Male
Contact address*:
Country*:
E-mail*:
Telephone:
Fax:
Work place / Institution*:
Specialty/degree*:    
Obtained in year*:  
3 years of neurological or comparable training
Place:   Dates:
4 months of EEG training
Place:   Dates:

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.
Are you able to participate without this financial support:  Yes      No
If you apply for financial support, please justify your request:
I confirm that I have not been granted another bursary from the CEA or ILAE for the year 2009*:  Yes      No
I have applied for another bursary from the CEA or ILAE in the year 2009*:  Yes      No

If yes, for what course(s):


Documents to be sent by e-mail to office@epilepsy-academy.org, by fax (+49 521 144 4311) or by mail to Epilepsy Academy Office, Maraweg 21, 33617 Bielefeld, Germany.

  1. Signed confirmation of the neurology department on the 3 years of neurological or comparable training
  2. Signed confirmation of the neurology department on the 4 months of EEG training
  3. CV
  4. List of publications
I confirm that all information provided by me is truthful*


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.