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Young Neurosurgeons Forum

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Young Neurosurgeons Forum Document Transcript

  • 1. Membership Application Form Young Neurosurgeons Forum Membership of Young Neurosurgeons Forum, Pakistan is open to all Pakistani neurosurgeons who are within ten years of acquiring their first neurosurgical qualification. Those neurosurgical residents/trainees, who have completed their residency/training and are eligible to appear in their neurosurgical postgraduate examination can also join as full members of the Forum. Section 1 – BIOGRAPHICAL DATAFull NamePositionInstitutionInstitutional AddressCity Post CodeTelephone ( ) Fax ( )Home AddressCity Post CodeTelephone ( ) Fax ( )Email @Preferred Mailing Address Home OfficeDate of Birth Nationality Page 1
  • 2. Section 2 – PROFESSIONAL DATAQualifications Basic Professional*Date of first neurosurgical postgraduate qualification** In case of residents / trainees, please give qualification working for & the expected date of examinationInstitution from which neurosurgical qualification has been (or is expected to be) obtainedExperience in Neurosurgery: Post-Qualification (in years & months) Total duration Position InstitutionExperience in Neurosurgery: Pre-Qualification (in years & months) Total duration Position InstitutionPublications (including dissertation/thesis) Please attach additional pages if necessaryInterests (Neurosurgical)Interests (Other) For office use only Admitted Rejected Signature of the YNF official YNF Seal Designation Date Page 2