European Board Examination in Paediatric Surgery
The undersigned wishes to apply for the Examination of The European Board in Paediatric Surgery
Please complete in
BLOCK CAPITALS
Surname: ……………………………………………
First Name: ……………………………………………
Private Address:
Hospital Address:
Date of Birth:………………………Place and Country of Birth: …………………………
Country of Citizenship: ……………………………………………
Country of Training: ……………………….......……………………
First Language: …………………….................................……………
Fluency in Languages: ……………...............................……………
I am a qualified Paediatric Surgeon: Yes
No Year of Qualification: 19…………… 0r 20…………………
Medical School/University (name and address)
Date of Graduation…………………………
Specialist Training: (Name and address of Centre and Surgeon[s] in charge of Training)
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From To
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From To
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From To
Accreditation in Paediatric Surgery
(Name, number and date of certificate issued by University, Medical Association or Government Body)
…………………………………………………………………………………
Present Position: (Since ........................):
……………………………………………………………………………………
Last Position Held:
………………………………………………………………………………………………
From: …………………… To: …………………
Additional Information:
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Enclosures: | Copy of Certificate or proof of accreditation as a Paediatric Surgeon |
| Copy statement last year Residency Training Programme in Paediatric Surgery signed by Trainer from the Training Centre |
| Submission of the official signed log book of Trainee |
Payment of Examination Fee (50 euro
Payment of Examination Fee can be made by: (please tick only one circle)
| £ 250 Cheque (Eurocheque or cheque drawn against a British Bank) and sent with this form to the EBPS Certification Secretary |
OR
| Bank Transfer to: |
Bank of Scotland
Sort Code 800743
816 Govan Road
Glasgow G51 3UP
Account Number 00101289
Scotland
Signature: Date:
Please ensure that you have answered all the questions
Some items may not be applicable In that case, please fill in "n/a"
It is essential that you send in either a copy of your certificate of accreditation as a Paediatric Surgeon or other proof of accreditation
This form and enclosures to be returned by mail to:
Mrs Rosemary Mackenzie
EBPS Certification Secretary
17 Greenfield Street
Glasgow G51 3PW
Scotland
