APPLICATION FORM FOR APSS FELLOWSHIPS 2020
PERSONAL PARTICULARS
First name *
Your answer
Last name *
Your answer
Gender *
Nationality *
Your answer
Date of birth *
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Place of birth *
Your answer
Correspondence address *
Your answer
Email *
Your answer
Phone number (Mobile) *
Your answer
Current position *
Your answer
Institution address *
Your answer
EDUCATION BACKGROUND
Basic Medical Degree - Qualification *
Your answer
Medical school / centre *
Your answer
Date of graduation *
MM
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DD
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YYYY
Postgraduate Orthopaedic Education - Qualification *
Your answer
Medical school / centre *
Your answer
Date of graduation *
MM
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DD
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YYYY
RESEARCH AND PUBLICATIONS
Are you interested in spine research? *
Oral presentation (number) *
Your answer
Poster presentation (number) *
Your answer
PREVIOUS FELLOWSHIPS
Previous spine training Fellowship (if any) *
Name of the fellowship centre
Your answer
Date of fellowship commencement
MM
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DD
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YYYY
Duration
Your answer
Have you ever been awarded an APSS Fellowship ? *
If "yes", please provide the year:
Your answer
APSS MEMBERSHIP
Are you an active, paid-up APSS member? *
EXPERIENCE AND AREA OF INTEREST
How many years or months of experience in spine? *
Your answer
Area of interest in spine (list 3 areas of interest): *
Your answer
APSS FELLOWSHIPS APPLICATION
Please select the fellowship programme you are applying for (You may select more than one programme. Please note that you will be eligible for only 1 fellowship award from these selections): *
Required
Please rank the selected fellowship programme in order of preference. (1 being the most preferred programme and 3 being the least preferred programme):
1
2
3
APSS DePuy Synthes Clinical Fellowship (3 weeks, 1 centre)
APSS DePuy Synthes Travelling Spine Fellowship (3 weeks, 3 centres)
APSS-Ganga Hospital Fellowship (3 weeks, 1 centre)
Please rate your preference to participate in the fellowship programmes in the following countries (1 being the most preferred and 7 being the least preferred): *
1
2
3
4
5
6
7
Australia
Hong Kong
India
Japan
Korea
Malaysia
Singapore
Explain briefly the reasons of your application, and selection of programmes and preference of countries : *
Your answer
How did you find out about APSS Fellowship Programmes? *
Your answer
APSS ACTIVITIES' PARTICIPATION
Have you participated in any of APOA and APSS past activities? (E.g. Scientific Congress / Meeting; Operative Course; Basic Course; Cadaveric Course; etc.) *
Name the activity:
Your answer
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