PCCR Application Form

Section 1: Personal Details

Application Type*(Required)

Category 1 (without qualifying examination)

Category 2 (with qualifying examination)

Either

EUSTM Membership *(Required)

Yes

Family Name(Required)

Forename(s) *

City*(Required)

Country*(Required)

Email Address*(Required)

Section 2: Expertise Areas / Disciplines

No. 1

No. 2

No. 3

No. 4

Section 3: Academic Record and Professional Experience

Highest Qualification No.1:(Required)

Degree No.2 (if any):

Degree No.3 (if any):

Degree No.4 (if any):

Current Position

Previous position (if any)

Section 4: Talks / Presentations / Posters

No.of oral talks / presentations at int. congresses:

Number of posters at int. congresses (approx):

Section 5: Memberships (Professioanl / Scientific / Medical organziations)

Memberships (Professional/Scientific/Medical Organizations)

Awards / Achievements / Honors

Section 6: PCCR Support Statement

Please describe why should be considered for the PCCR (Supporting Statement) (Maximum 300 Words)*

Upload Your CV (pdf) *

Max. file size: 64 MB.

Section 5: Declaration & Check List

attachment(Required)

I confirm that information provided in the form and in my CV are accurate.

I have attached the CV/Resume

I confirm that I have read and obey the Academy’s Rules, Regulations and policies.