ILAE Academy Level 3 Training Program Survey

Participants who have completed the ILAE Level 2 Program are eligible to apply for support of a Training Visit to further their education and training in person.

Applications must include:

Submission of this online application
Support letter from your Home Institution (download form) or motivation letter
Support letter from your Host Institution (download form)
Upload your Level 2 Certificate

Please gather all needed documents before proceeding with the application.

Applications will be accepted on a rolling basis until funding is exhausted.

1.Applicant Information(Required.)

Title:

Surname/Family Name:

Given Name:

Date of Birth (dd.mm.yyyy):

Nationality:

Current Affiliation:

Postal Address (Work):

Telephone Number (Including country code):

Institutional Email:

2.Declaration of adherence to Level 3 program of the ILAE Academy:(Required.)

I have working knowledge of English OR of the language of the host country.

I am currently undergoing my training or have recently finished my training in a country represented by an ILAE chapter. Please name the chapter:

3.Home Institution Information(Required.)

Name of Institution:

Department:

Postal Address

Postal Code:

Country:

Chair/Head of Department

Supervisor at Home Department

Supervisor Telephone (including country code):

Email of Supervisor:

4.Host Institution Information(Required.)

Name of Institution:

Department:

Postal Address

Postal Code:

Country:

Chair/Head of Department

Mentor at Home Department

Mentor Telephone (including country code):

Email of Mentor:

6.Please upload your ILAE Academy Level 2 Certificate.(Required.)

No file chosen

7.Please upload your Home Institution Support Letter or a motivaion letter(Required.)

No file chosen

8.Please upload your Host Institution Support Letter.(Required.)

No file chosen

9.Are you applying for a clinical or research Training Visit?(Required.)

Clinical

Research