European Board of Pathology

Examination Committee

EBP

Application form for the 2010 European Board Examination in Pathology Krakow Poland
The undersigned wishes to take the examination

Only forms which are completely filled out will be accepted
Please use a typewriter!
The forms and enclosures must be sent by mail
Secretariat:
Prof.dr.Claude Cuvelier
Head Academic Deparment of Pathology
Ghent University
UZG Blok A 5th floor
De Pintelaan 185
B 9000 Ghent
Belgium
Tel.+ 32-9-3323663
Fax. +32-9-3324965
email : Claude.Cuvelier@ugent.be

Family name		: ________________________________________________________________

First name		: ________________________________________________________________

Private address	(Street)	: ________________________________________________________________

	(ZIP-code)	: ________________________________________________________________

	(Place)	: ________________________________________________________________

	(Country)	: ________________________________________________________________

	(Tel/Fax)	: ________________________________________________________________

	(Email)	: ________________________________________________________________

Hospital		: ________________________________________________________________

Hospital address	(Street)	: ________________________________________________________________

	(ZIP-code)	: ________________________________________________________________

	(Place)	: ________________________________________________________________

	(Country)	: ________________________________________________________________

	(Tel/Fax)	: ________________________________________________________________

	(Email)	: ________________________________________________________________

	Date of birth	: ________________________________________________________________

	Place and country of birth:	: ________________________________________________________________

	Country of citizenship	: ________________________________________________________________

	Country of training	: ________________________________________________________________

	I am a qualified pathologist	: Yes / No (Please enclose a photocopy of your certificate)

	I am a resident in training	: Yes / No (Training will end before July 2009)

	Year of registration as pathologist	: ________________________________________________________________

	in European country	: ________________________________________________________________

	Specialist training

	Medical School/University/Hospital of training	: ________________________________________________________________

	Name and address of center	: ________________________________________________________________

	and head of training	: ________________________________________________________________

	From	: _____________________________ to:______________________________

	Accreditation in Pathology Name, number and date of certificate, issued by	: ________________________________________________________________

	Present position: ______________________________________________ ______________________________________________	Since: ______________________________________________ ______________________________________________

	Last position held: _______________________________ ______________________________________________	From:_____________________to:___________________

Additional information

____________________________________________________________________________________________________

	Enclosures:

	1. Copy of certificate or proof of accreditation as a pathologist	o

	2. Copy statement last year Residency Training Programm in Pathology	o

	3. Recent photograph	o

Payment of examination fee ( 400 EURO)
An examination fee of 400 EURO will be levied for participation in this examination. Please assure that there are no banking costs for the ECEB accout. This fee excludes the travel and lodging expenses of the candidate.

The registration fee will be payed by:

Payment transferred to:
ECEB of Pathology
Bank account number:001-5038095-88
Fortis Bank Gent
IBAN: Be56 001503809588
BIC: GEBABEBB

The deadline for sending in your application form to take the examination and for payment of the examination is 31 July 2010.

Cancellation
In the event of cancellation full refund of the examination fee minus 15% for administration costs, may be made up to six months before the examination and 50% of the fee up to three months before the examination. Only written cancellations shall be accepted. No refund will be made if the cancellation request is received at the secretariat of the Examination Committee of the the European Board of Pathology after August 1, 2010. Refunds will be processed in December 2010.

Signature:___________________________________________________ Date:_______________________________________

Please make sure that you have answered all the questions and that you have included all the requested
documents. It is essential to send in either a copy of your certificate of accreditation as a pathologist
or other proof of accreditation.

Please send this form and the enclosures by mail before August 1, 2010.

Prof. dr. Claude Cuvelier
Head Academic Department of Pathology
Ghent University
UZG Blok A 5th floor
De Pintelaan 185
B 9000 Ghent
Tel. + 32-9-3323663
Fax. +32-9-3324965
e-mail: Claude.Cuvelier@ugent.be