ILAE Academy Level 3 Training Program

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.

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* 1. Applicant Information

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:

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* 2. Declaration of adherence to Level 3 program of the ILAE Academy:

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:

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* 3. Home Institution Information

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:

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* 4. Host Institution Information

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:

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* 5. How did you learn about the ILAE Academy?

Colleague

Flyer

Newsletter

YES/ILAE Website

Congress

Other (please specify)

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* 6. Please upload your ILAE Academy Level 2 Certificate.

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* 7. Please upload your Home Institution Support Letter or a motivaion letter

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* 8. Please upload your Host Institution Support Letter.

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* 9. Are you applying for a clinical or research Training Visit?

Clinical

Research