PCCT Application Form Application Form Section 1: Personal DetailsApplication Type* Category 1 (without qualifying examination) Category 2 (with qualifying examination) Either EUSTM Membership * Yes No Family Name(Required) Family Name * Forename(s) * Forename(s) * City*(Required)Country*(Required)Email Address*(Required) Section 2: Expertise Areas / DisciplinesNo. 1No. 2No. 3No. 4Section 3: Academic Record and Professional ExperienceHighest Qualification No.1:(Required)Degree No.2 (if any):Degree No.3 (if any):Degree No.4 (if any):Current PositionPrevious position (if any)Section 4: Talks / Presentations / PostersNo.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 / HonorsSection 6: PCCR Support StatementPlease describe why should be considered for the PCCR (Supporting Statement) (Maximum 300 Words)*Upload Your CV (pdf) *Max. file size: 3 GB.Section 5: Declaration & Check Listattachment(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.
