Martin Allgöwer Trauma Fellowship Application

FAMILY NAME, GIVEN NAME, DATE OF BIRTH, NATIONALITY:


PERMANENT HOME ADDRESS, HOME PHONE NUMBER:

NAME, ADDRESS, TELEPHONE, AND FAX OF
UNIVERSITY/HOSPITAL:


PRESENT POSITION:


HEAD OF DEPARTMENT:

LANGUAGES SPOKEN:


PLEASE SELECT ONE OF THE FOLLOWING:
ENGLISH
SPANISH
FRENCH
GERMAN
OTHER

Medical Studies:
NAME AND ADDRESS OF SCHOOL, DURATION,
DATE OF GRADUATION:


Post Graduate Education:
LOCATION, DURATION, AND QUALIFICATION OF
GENERAL SURGERY:


LOCATION, DURATION, AND QUALIFICATION OF
ORTHOP. SURGERY:


DETAILS ABOUT SPECIAL TRAINING IN TRAUMA:
(shock, polytrauma, hand injuries, closed and open
treatment of fractures, etc.)


DO YOU UTILIZE ORIGINAL AO ASIF INSTRUMENTS & IMPLANTS:
YES
NO


ARE YOU RESEARCH ORIENTED: YES
NO
IN WHICH AREAS:


ARE YOU CURRENTLY ACTIVE IN RESEARCH: YES
NO
CLINICALLY, EXPERIMENTALLY, PLEASE EXPLAIN:

PUBLICATIONS:
YES
NO
(please attach or send your bibliography)

IN WHICH FIELDS ARE YOU INTERESTED:
(Trauma, hand surgery, maxillofacial, spine, others)


WHERE AND WHEN DID YOU TAKE THE AO BASIC
AND ADVANCED COURSES:


ARE YOU AN AO FACULTY MEMBER:
YES
NO

ARE YOU AN AO NORTH AMERICA MEMBER:
YES
NO

WHAT DO YOU EXPECT FROM YOUR FELLOWSHIP EXPERIENCE,
WHERE AND WHEN WOULD YOU LIKE TO GO TO TAKE IT,
AND WITH WHOM:


PLEASE ENCLOSE THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION:
1) MINIMUM OF TWO LETTERS OF RECOMMENDATION
2) CURRICULUM VITAE
3) LIST OF PUBLICATIONS AND/OR LECTURES
4) TWO PHOTOGRAPHS

PLEASE SEND COMPLETED FORM TO: