Application Form

EAN Spring School May 12-15, 2016

All electronic documents must be received not later than:January 31st, 2016

First Name: Surname:

Title:Date of birth (dd/mm/yyyy):Mr. Ms. Years of postgraduate training in clinical neurology ...........

Complete Postal Address: Street, no. Postcode & City Country

Work Address: Department Street, no. Postcode &City Country Telephone: Fax: E-mail:

IMPORTANT: the application form must be accompanied by: structured curriculum vitae including list of publications (max. 10) letter of recommendation from a senior neurologist proof of neurology experience/eligibility (from programme supervisor, programme director) recommendation letter from National Neurological Society not mandatory

Applications should be sent:by e-mail to: dohnalova@eaneurology.org

Applications must be typed, and not handwritten! E-mails without subject will not be considered.The maximal size of all attachments together is up to 5MB. We accept documents: application form word format (only) other documents in word, pdf, jpg formatsIncomplete applications will not be accepted.

Visa procedure

Participants from certain countries must apply for visa. If you are from the country that requires the visa please specify:

I have a valid visa I will apply for visa

Please, see the requirements of Ministry of Foreign Affairs of the Czech Republic www.mzv.cz, English version: http://www.mzv.cz/jnp/en/information_for_aliens/short_stay_visa/index.html

The travel document must have been issued within the last ten years and must be valid at least 90 days after the intended departure from the Czech Republic/Schengen area. This condition is valid also for persons travelling within the visa free regime.

Required data*:

surnamefirst namedate of birth (day month year)place of birth (town) permanent address post code, city, street, no. (according to your passport)sexnationalitypassport numbercopy of passport (page of identification)

Complete postal address for sending the invitation letter: Street, no., flat no. Postcode & City Country

*All of this information is absolutely necessary.