Eurepa Distance Education Programme

APPLICATION FORM

This form will be sent automatically to office@epilepsy-academy.org. The required attachments
should be sent by e-mail to the same address, by fax to +49 521 144 4311 or by mail to Eurepa
Secretariat, Maraweg 21, 33617 Bielefeld, Germany.



* denotes mandatory data
 
Course for which you apply*:
First name*:   Last name*:
Country*:   Year of birth*:
  Gender*:
F   M
Current position*:
Contact address*:
E-mail*:
Telephone:   Fax:
Specialty/degree*:   Obtained in year*:

3 years of neurological or comparable training
Place:   Dates:

4 months of EEG training
Place:   Dates:
 

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

Do you wish to apply for financial support (bursary)*:
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 as soon as possible.

Please make sure that you keep us updated of any changes in your application.

Attachments to be sent by e-mail to office@epilepsy-academy.org, by fax (+49 521 144
4311) or by mail to Eurepa Secretariat, 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

Please note that only applications received within deadline limits and with all necessary
attachments can be considered.