European Association of

PercutaneousCardiovascular Interventions

INTERVENTIONAL CARDIOLOGY EDUCATION AND TRAINING GRANT

Programme 2017-2018 – Part A

1- APPLICANT’S DETAILS:

Family Name
First Name
Sex /  Male  Female
Date*& place of Birth
Are you an EAPCI Member? /  Yes  No / ESC ID:

* (dd/mm/yyyy).

  • Applicants born before 15 January 1981or not at early stage of training (i.e. internal medicine and cardiology training completed, candidates about to enter interventional cardiology training) are not eligible for EAPCI grants. No exception will be made.

Preferred postal address / Other postal address
 Home address  Work address /  Home address  Work address
Country of residence (tax purpose)
Country of citizenship
Phone number
Email address

2- TITLE TOPIC OF THE EDUCATION & TRAINING PROJECT:

Topic /  Percutaneous coronary interventions with focus on metallic and bioresorbable stent technology
 Interventional pharmacology in patients with ACS and structural heart disease
 Transcatheter aortic valve implantation
 Transcatheter mitral valve interventions
 Structural heart disease interventions with focus on left atrial appendage closure, closure of PFO and atrialseptal defects, paravalvular leak closure etc.
 Intracoronary imaging (IVUS, OCT, NIRS) and physiologic lesion assessment with FFR
 Carotid and peripheral arterial interventions
 Imaging for structural heart intervention
Title :

3- PERIOD FOR WHICH THE GRANT IS REQUESTED:

Available date to start the training

Please note that the 12-month period must start between June & December 2017.

4- DESCRIPTION OF PROPOSED EDUCATION AND TRAININGFELLOWSHIP PROGRAMME TO BE UNDERSTAKEN (250 WORDS MAXIMUM).

A detailed proposal must be attached including appropriate references. Proposal should include the description of the Education and Training programme (what you would like to learn, how you would like to do it, which type of procedures and how many of them you would be able to perform during training period, how you wantto use your skills after returning to home country and if any research activities are envisaged etc)

Failure to submit a detailed proposal (2-4 pages) will mean that your application will be rejected.

5- APPLICANT’S ACADEMIC RECORD (IN CHRONOLOGICAL ORDER):

Year / Academic Institution / Degree(s) gained / Subject

6- POSTGRADUATE CAREER INCLUDING CURRENT EMPLOYMENT (IN CHRONOLOGICAL ORDER):

Dates / Place of work / Positions held

7- PRESENT APPOINTMENT:

Employer / Source of funding
Tenure
Grade / Status
Date of entry to current grade
Current position

8- CAREER INTENTIONS AFTER THE GRANT PERIOD:

9- RESEARCH EXPERIENCE:

10- LANGUAGES SPOKEN BY THE APPLICANT:

Level
English /  Mother tongue  Fluent  Intermediate Basic  Beginner
German /  Mother tongue  Fluent  Intermediate  Basic  Beginner
French /  Mother tongue  Fluent  Intermediate  Basic  Beginner
Spanish /  Mother tongue  Fluent  Intermediate  Basic  Beginner
Italian /  Mother tongue  Fluent  Intermediate  Basic  Beginner
Dutch /  Mother tongue  Fluent  Intermediate  Basic  Beginner
Other*: /  Mother tongue  Fluent  Intermediate  Basic  Beginner
Other*: /  Mother tongue  Fluent  Intermediate  Basic  Beginner

* Please specify if applicable.

11- PUBLICATIONS IN REFEREED JOURNALS RELEVANT TO THIS APPLICATION:

Details of papers may be added, abstracts can be included.

State of journal / Title / Page Number / Co-authors
Details of papers in press
Abstract
State of journal / Title / Page Number / Co-authors
Details of papers in press
Abstract

12- CONTACT DETAILS TO WHOM PARTS B AND CHAVE BEEN PASSED

PART B – Present Head of Department or Supervisor
Name
Address
Telephone number
Email address
PART C – Independent Referee
Name
Address
Telephone number
Email address

13- DETAILS OF OTHER AWARDS OR GRANTS FOR WHICH YOU ARE CURRENTLY APPLYING:

14- INSURANCE STATUS:

For sickness and accident – please precise if you benefit from insurance via your future institution or if you subscribed/will subscribe to a private one.

15- HOW DO YOU PLAN TO BE INVOLVED IN THE EAPCI ACTIVITIES AFTER YOUR GRANT:

ACCEPTANCE AND CONDITIONS:

If my application is successful, I agree to accept the conditions posed by the EAPCI.I certify to have read and understood these terms and conditions.

Personal Data Privacy

The information collected is subject to a computerised process to record, evaluate and track your grant application. The recipients of the data are:

• The staff in charge of processing EAPCIEducation and Training Grant applications and, where a grant is awarded, the staff in charge of paying the grant monies.

• Persons to whom the request will be sent for review and evaluation.

In accordance with the French law N°78-17 of January 6, 1978, amended in 2004, relating to the protection of individuals with regard to the processing of personal data, you have a right to access and rectify information concerning you, which you can exercise by contacting:

Customer Services

European Society of Cardiology

Les Templiers, 2035 Route des Colles

06903 SOPHIA ANTIPOLIS. FRANCE

You can also, for legitimate reasons, oppose the processing of data about you.

Signature of Applicant / Date

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