International League against Epilepsy - Commission on European Affairs / European Advisory Council
European Epilepsy Academy
Lithuanian Society for Epileptology

2nd Migrating Course on Epilepsy

June 1-8, 2008     Trakai, Lithuania

Application Form

This form will be sent automatically to endziniene@gmail.com and petra@epilepsy-academy.org.

Deadline for application: January 15, 2008



* denotes mandatory data
 
First name*:   Last name*:
Country*:
Year of birth*:   Gender*:
F   M
Current position*:
Contact address*:
E-Mail*:
Home telephone:
Work telephone*:
Fax:
Specialty/degree*:   Obtained in year*:
Title of the case report 1*:
Title of the case report 2*:
Video case report*:
Y   N
  Notes:
 

NB: Only one CEA or ILAE bursary per year is possible per person.

Do you wish to apply for financial support (bursary covers registration fee)*:
Please note that, in case of a bursary request, your name will be saved in an ILAE database accessible to ILAE course organizers only. 		  Y   N
Are you able to participate without this financial support:   Y   N
I confirm that I have not been granted another bursary from the CEA or ILAE for the year 2008*:   Y   N
I have applied for another bursary from the CEA or ILAE in the year 2008*:   Y   N
   If yes, for what course(s): 
If you apply for financial support, please justify your request in the box below:
 
I confirm that all information provided by me is truthful*

Applicants will be informed of the outcome of their application by February 29, 2008.