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3rd BALKAN AND EASTERN EUROPEAN MASTERCLASS IN CLINICAL ONCOLOGY
08- 12 May 2013, Dubrovnik, Croatia
APPLICATION FORM (DEADLINE: 18 March 2013)
Please save this file, complete it with your contact and professional details and return it with required
documents to: [email protected]
The application form should be submitted as a Word file and electronically only.
The acknowledgement of receipt will be sent within 72 hours.
To complete the application, the following documents are required:
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Letter describing motivation for attending
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Supporting letter from head of department or mentor
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CV with list of publications (if the list of publications is not provided, it will be assumed that no articles
have been published)
Your details:
Family name
First name
Date of birth
Gender
Institute
Department
Work Address
Zip code
Town
Country
Phone number
Fax number
Mobile phone:
e-mail (*)
* All correspondence regarding your application will be sent by e-mail.
Specialty




Medical oncologist
Radiation oncologist
Clinical oncologist
Else:
Please describe here your 3-5 years’ experience in clinical oncology:
Year / period
Description
Please describe here your involvement in scientific activities and clinical trials:
Year / period
Description
How would you divide the percentage of your daily work that you are involved with (sum should be 100%):
Brain tumours
Breast cancer
Colorectal cancer
Gastrointestinal cancer
Gynaecological cancer
Haematological diseases
Head and neck cancer
Lung cancer
Melanoma and sarcoma
Palliative care
Paediatric oncology
Urological cancer
Supportive care
Else:
Else:
Else:
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
How would you rate your English, from 1 (basic) to 5 (mother tongue) ?
Rate
Please insert your abstract in the table below. It is important that the abstract is submitted as a Word file.
The abstract:
Should describe a clinical case relating to one of the subjects of the Masterclass, in the format of a clinical
grand round rather than a publication article.
Should not report trials or research projects.
Should include three questions relating to the clinical case that the applicant puts to the faculty for
discussion.
Subject
Title
Author
Introduction
Diagnostic
considerations
Treatment
Results /
Follow-up
Question 1
Question 2
Question 3
The abstract describes a clinical case in of the subjects of the Masterclass
Please mark the subject:
o Lung cancer
o Gastro-intestinal cancers
o Breast cancer