ESOP-ESO ADVANCED MASTERCLASS INONCOLOGY PHARMACY

21-25October 2013, Dreseden, Germany

APPLICATION FORM (deadline: 30July 2013)
Documents to be submitted with the application form at the application deadline:
- Letter describing motivation for attending
- Curriculum vitae with list of publications (if the list of publications is not provided, it will be assumed that no articles have been published)
- Certificates of attendance of the basic and intermediate masterclass in oncology pharmacy or equivalent (eg. BCOP, DGOP Weiterbildung Onkologische Pharmazie)
- Proof of at least 2 years’ experience in oncology pharmacy (job reference)
- Description of 2 cases of your own practicein oncology pharmacy (abstracts, see page 3)

Please save this file, complete it with your contact and professional details, your abstracts and return it with required documents to the ESOP Membership Service –

The application form should be submitted as a Word file and electronically only.

The acknowledgement of receipt will be sent within 72 hours.

Your details:

Family name
First name
Date of birth
Gender
Institute
Department
Address
Zip code
Town
Country
Phone number
Fax number
Cell number
e-mail (*)

*All correspondence regarding your application will be sent by e-mail

Please describe here your experience in clinical oncology pharmacy:

Year / period / Description

Please describe here your involvement in scientific activities and/or clinical trials:

Year / period / Description

How would you divide the percentage of your daily work that you are involved in oncology pharmacy:

%

How would you rate your English, from 1 (basic) to 5 (mother tongue) ?

Rate

Please insert your abstracts in the table below. It is important that the abstractsare submitted as a Word file and sent by e-mail.

The abstract:

-Should describe a clinical case relating to one of the subjects of the Masterclass, (format: example see at

-Should not report trials or research projects.

-Should include three questions relating to the clinical case that the applicant puts to the faculty for discussion.

Abstract 1
Subject
Title
Author
Introduction
Diagnostic considerations
Treatment
Results /
Follow-up
Question 1
Question 2
Question 3
Abstract 2
Subject
Title
Author
Introduction
Diagnostic considerations
Treatment
Results /
Follow-up
Question 1
Question 2
Question 3