EANS Examination in Neurosurgery 6th September 2008 1600 - 1915
in Antwerp, Belgium and Uppsala, Sweden.

** Please note that the deadline for entries for the written **
** examinations in September 2008 is 1st July 2008           **

DO NOT COMPLETE THIS FORM OR PAY THE EXAM FEE IF YOU ARE ON THE EANS TRAINING COURSES

CANDIDATES FROM COUNTRIES OUTSIDE THE EANS CAN ONLY TAKE THE EXAM FOR SELF ASSESSMENT

Fee:	 	in European training program 		100 Euros

		from non-European training program 	200 Euros

		after completing the training program 	200 Euros
		



Name: __________________________Date of birth: ____________________

City and Country of birth: ____________________Nationality: ______________

Start of Neurosurgical training (year/month): _____/______

Department: __________________Hospital____________________________

Hospital address: _________________________________________________

______________________________________________________________

Home address: ___________________________________________________

______________________________________________________________

E-mail: _________________________________________________________
Phone number/home: _____________________work: _____________________
Cell phone number: __________________________________________

Signature of participant: ___________________________________________

Signature of Head of Department: ____________________________________

To:
Dr Kristina Cesarini, Dept of Neurosurgery, University Hospital, 75331 Uppsala, Sweden
E-mail: Kristina.Cesarini@neurokir.uu.se

Please include:
-A birth certificate/copy of your passport
-A copy of your Medical Degree
-A copy of your curriculum vitae stating your medical education, previous and present position as a doctor/neurosurgeon and signed by your chief.
-A receipt of payment: se above for fee, deposited in the following account: 
Bank: Fortis Bank Gent
Address: Kouter 8 - 9000 Gent - Belgium
IBAN: BE66 2900 0868 3743
BIC: GEBABEBB

Please also contact the EANS Secretariat (eans_secretariat@philsparrow.co.uk).