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APPLICATION FORM FOR FELLOWSHIP OF THE
EUROPEAN SOCIETY OF CARDIOLOGY (F.E.S.C.)
EUROPEAN ESC Application Deadline: 15 MAY 2003
SOCIETY OF
CARDIOLOGY

FAMILY NAME: ………………………………………………………………… FIRST NAME(S): …………………………………………………………………………
OFFICE ADDRESS: ……………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………
POSTAL CODE: ………………………………… CITY: ……………………………………………………… COUNTRY ……………………………………………
TEL: …………………………………………………… FAX: ……………………………………………………… EMAIL: …………………………………………………
HOME ADDRESS: ………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………
POSTAL CODE: ………………………………… CITY: ……………………………………………………… COUNTRY ……………………………………………
TEL: …………………………………………………… FAX: ……………………………………………………… EMAIL: …………………………………………………
*I would prefer to receive any future correspondence to my: ❑ OFFICE ADDRESS
❑ HOME ADDRESS
Date of birth: …………………………………………………………………
Principal current professional activity: (check those applicable)
❑ HOSPITAL ❑ RESEARCH ❑ EDUCATION ❑ PRIVATE PRACTICE ❑ OTHER(S), SPECIFY:* …………………………………
Please indicate your areas of interest: …………………………………………………………………………………………………………………………………………
Are you
-Member from one of the 47 National Societies amliated to ESCI ❑ Yes ❑ No, which one(s)? …………………………………
- Member of one or several Working Groups of the ESC2 ❑ Yes ❑ No, which one(s)? …………………………………
- Member of the European Council for Cardiology Practice? ❑ Yes ❑ No
DOCUMENTATION - in English only:
The documentation that must accompany your application form depends on the category to which you belong. Please see the
relevant list of required documenta for each category as defined below. All accompanying documenta must be in English.
European Cardiologist Diploma awardees:
No documentation is required apart from this application form.
Board-Certified Cardiologists (who are not holders of the European Cardiologist Diploma)
❑ Proof of national qualification in Cardiology, including copies of all Medical Diplomas,
❑ Supporting letter from the Board of your National Society of Cardiology, which must be amliated to the ESC
❑ Supporting letter from a Fellow of the ESC or from the Head of the Institution where the Candidate is employed.
Scientists
❑ Structured CV following the template on the page hereafter
❑ Copies of all medicai or other academic Diplomas
❑ Supporting letter from a Fellow of the ESC or from the Head of the Institution where the Candidate is employed.
❑ List of the 5 most important publications in the cardiology field, published in peer-reviewed journals (fill in the template
provided hereafter)
Others
❑ Stnuctured CV following the template provided hereafter
❑ Copies of all medicai or other academic Diplomas
❑ Supporting letter from the appropriate Board of the appropriate Specialist Society or Professional Organisation, e.g. Board
of National Society of Cardiology or other Medical Association in your own country.
❑ Supporting letter from a Fellow of the ESC or from the Head of the Institution where the Candidate is employed.
❑ List of the 5 most important publications in the cardiology field, published in per-reviewed joumals or joumals with impact
factor (fill in the template provided hereafter)
PAGE 4 & 5: STRUCTURED CURRICULUM VITAE & STRUCTURED PUBLICATION LISTS FORM REQUIRED FOR CATE-
GORIES “SCIENTISTS” AND “OTHERS”.
Please retum application and documentation before 15 Mav 2003. to the European Society of Cardiology,
National Society 8 Member Relations Dept., 2035 route des Colles, B.P. 1 7g, FR 06903 Sophia-Antipolis, France
You trave personal data which is, according to the Law on data process/ng and C/v/l Liberties 78-17 of 6 Januarg1978, registered with the ESC. You trave
the absolute right to acces* amena and oppose any use of this personal data by contacting (in writing) the ESC National Soc/ety and Member Relat/ons at
the address ment/oned acove. Unless otherw/se /nformed, the ESC may sena you /nformat/on about /ts acUvffles from Ume to t/me.

Il presente Form e il Regolamento della Fellowship della ESC sono disponibili all’indirizzo internet:
www.escardio.org/fellowship/fellows/fesc_application_form2003.pdf

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