European Board Examination in Neurological Surgery – Part I
21stJanuary 2017, 15:00 – 19:15
Vilnius, Lithuania
Please note that the deadline for submission of this form is 16stDecember 2016.
In case the number of application exceeds the exam capacity, the applications can be closed prior to the above date.
DO NOT COMPLETE THIS FORM OR PAY THE EXAM FEE IF YOU ARE ON THE EANS TRAINING COURSES!
Surname: ______First Name(s): ______Nationality: ______
Date of birth: ______Place of birth: ______Start of Neurosurgical training (year/month): _____/______
Department: ______Hospital: ______
Your current position (resident/registrar or qualified NS/consultant etc.): ______
Hospital address: ______
______
Home address: ______
______
E-mail (for all correspondence incl. results and certificate): ______
Phone number work: ______Cell phone number: ______
Signature of participant: ______
Signature of Head of Department: ______
Please send this form electronically to Visi Navarro–
Please include scanned copies of:
- Your birth certificate/passport
- Your Medical Degree
- Your curriculum vitae stating your medical education, previous and present position as a trainee/neurosurgeon and signed by your chief.
The payment of the examination fee should be made to the account below no later than two weeks after the application was approvedby the EANS office. Please state your name and that it is for the Vilnius examination 2017 and don’t forget to cover all bank charges yourself.
Bank: BNP Paribas Fortis Sint-Denijs-Westrem, Kortrijksesteenweg 1176, 9051 Sint-Denijs-Westrem, Belgium
IBAN: BE24 0014 9428 8838
BIC: GEBABEBB
Account name: Examination Fee
Beneficiary address:EANS wzv, Kortrijksesteenweg 1142 bus 5, 9051 St-Denijs-Westrem, Belgium
Fees:
Neurosurgeons in training program in EANS member country100 Euros
Neurosurgeons in training program in non-EANS member country200 Euros
Neurosurgeons after completing the training program 200 Euros
Please kindly note that it can take up to 2 weeks to process applications for the exam.