Register for the Board Exam

Application form for the 2017 European Examination in Pathology Amsterdam, the Netherlands 2nd September 2017
The undersigned wishes to take the examination
Only forms which are completely filled out will be accepted
Please use a typewriter!
The forms and enclosures must be sent by mail or by e-mail
Secretariat:
Prof.dr.Claude Cuvelier
Deparment of Medical and Forensic Pathology
Ghent University
UZG PAD
De Pintelaan 185
B 9000 Ghent
Belgium
Tel.+ 32-9-3323676
email : Claude.Cuvelier@ugent.be
Family name : ________________________________________________________________
First name : ________________________________________________________________
Private address (Street) : ________________________________________________________________
(ZIP-code) : ________________________________________________________________
(Place) : ________________________________________________________________
(Country) : ________________________________________________________________
(Tel/Fax) : ________________________________________________________________
(Email) : ________________________________________________________________
Hospital : ________________________________________________________________
Hospital address (Street) : ________________________________________________________________
(ZIP-code) : ________________________________________________________________
(Place) : ________________________________________________________________
(Country) : ________________________________________________________________
(Tel/Fax) : ________________________________________________________________
(Email) : ________________________________________________________________
Date of birth : ________________________________________________________________
Place and country of birth: : ________________________________________________________________
Country of citizenship : ________________________________________________________________
Country of training : ________________________________________________________________
I am a qualified pathologist : Yes / No (Please enclose a photocopy of your certificate)
I am a resident in training : Yes / No (Training will end before September 2017)
Year of registration as pathologist : ________________________________________________________________
in European country : ________________________________________________________________
Specialist training
Medical School/University/Hospital of training : ________________________________________________________________
Name and address of center : ________________________________________________________________
and head of training : ________________________________________________________________
From : _____________________________       to:______________________________
Accreditation in Pathology
Name, number and date of certificate, issued by
: ________________________________________________________________
Present position:

______________________________________________

______________________________________________

Since:

______________________________________________

______________________________________________

Last position held: _______________________________

______________________________________________

From:_____________________to:___________________

Additional information

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Enclosures:
1. Copy of certificate or proof of accreditation as a pathologist o
2. Copy statement last year Residency Training Programme in Pathology o
3. Recent photograph o

Payment of examination fee ( 500 EURO)
An examination fee of 500 EURO will be levied for participation in this examination. Please assure that there are no banking costs for the ECEB account. This fee excludes the travel and lodging expenses of the candidate.
The registration fee will be payed by:Payment transferred to:
ECEB of Pathology
Bank account number: BE6300-164-757-4908
Fortis Bank Brussels
IBAN: BE6300-164-757-4908
BIC: GEBABEBB

The deadline for sending in your application form to take the examination and for payment of the examination is 31 July  2017.

Cancellation
In the event of cancellation full refund of the examination fee minus 15% for administration costs, may be made up to six months before the examination and 50% of the fee up to three months before the examination. Only written cancellations shall be accepted. No refund will be made if the cancellation request is received at the secretariat of the Examination Committee of the European Board of Pathology after August 1, 2017. Refunds will be processed in December 2017.


Signature:___________________________________________________ Date:_______________________________________

Please make sure that you have answered all the questions and that you have included all the requested documents. It is essential to send in either a copy of your certificate of accreditation as a pathologist or other proof of accreditation.

Please send this form and the enclosures by mail or e-mail before July 31, 2017

Prof. dr. Claude Cuvelier
Department of Medical and Forensic Pathology
Ghent University
PAD building
De Pintelaan 185
B 9000 Ghent
Tel. + 32-9-3323676
e-mail: Claude.Cuvelier@ugent.be

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