Microsoft word - international application form.doc
International Application Form
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Street ___________________________________________________________________________
Town ___________________________________________________________________________
Postcode ___________________________________________________________________________
Country ___________________________________________________________________________
Telephone ___________________________________________________________________________
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Nationality ___________________________________________________________________________
Father’s Occupation ___________________________________________________________________________
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Suggested travel destination _________________________________________________________________________
yes no Do you need an invitation to get a visa? yes no
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How did you hear about zis? ___________________________________________________________________________
Annotations: applications are only accepted with a valid e-mail-adress the applicant can access regularly. All communication between zis and the participants is
zis never awards grants to young people who already attend university or college. Please refrain from applying if you will be already enrolled at the
please specify country and region zis has only very limited possibilities to support candidates in obtaining visa compulsory for all applicants even if over 18 years of age
Please fill in the form and add all additional material (e.g. project outline and budget plan) zis needs in English or German language. Applications must be sent via conventional mail. For details, see www.zis-reisen.de or our leaflet in English. Incomplete applications will be neither processed nor answered. Deadline for every year is February 15. zis Stiftung für Studienreisen • zis Foundation for Travel Grants
c/o Schule Schloss Salem • D-88682 Salem • Germany Telephone +49 7553 919332 • Telefax +49 7553 919301 • www.zis-reisen.de • info@zis-reisen.de
COMPTE RENDU DE LA CELLULE GESTION DES RISQUES DATE : 25/09/2012 Présents : M. Leguédois, A. Atbib, C. Divay, C. Eury, S. Guillard, R. Meurou, V. Hamel, V. Vaultier, L. Bréard, A. Giudicelli, M. Eury Analyse des signalements d’évènements indésirables o 2 évènements indésirables dont 1 grave o 6 incidents absence du médicament (Rémicade) pour une patiente accueil ie en
BRIAN S. KAHAN, D.O. CURRICULUM VITAE Business Address: Business Phone: BOARD CERTIFICATION American Board of Physical Medicine and Rehabilitation American Board of Physical Medicine and Rehabilitation- Pain Subspecialty Fellow Interventional Pain Physicians American Osteopathic Board of Physical Medicine and Rehabilitation American Board of Pain Med