/ The Foundation for the Development of Internal Medicine in Europe
and
The European Federation of Internal Medicine /

11th CLINICAL RESEARCH SEMINAR Paris

6 – 8 July 2015

Supported by

VENUE

La Maison du Poumon, 66 boulevard Saint-Michel, Jardin du Luxembourg, 75006 Paris, France

COURSE DATES

Monday 06.07.2015 to Wednesday 08.07.2015

(Residents arrival is set for Sunday 05.07.2014 and departure is set for Wednesday 08.07.2014 after lunch)

APPLICATION FORM

CLOSING DATE

17.04.2015ONLINE APPLICATION IS PREFERRED AT

Applicants must meet the following criteria:

  • Come from an EFIM member country and under the age of 35 years
  • Be able to communicate in English (this is essential since all lectures & interaction are in English)
  • Be towards the end of their training in Internal Medicine.
  • Have current or previous experience of ClinicalResearch

If you’re eligible as an applicant, please complete the following steps:

  • Type (or print clearly) your details below.
  • Note the ‘Additional Important Information’ on page 3.
  • Send the completed form and your current CV to

Romy Alig at FDIME

e-mail:

PLEASE TYPE DETAILS BELOW and send your CV (including any Publications)

FAMILY NAME
First Name(s)
Postal Address
Country
Date of Birth
Nationality
Gender (Male/Female)
E-mail address 1
E-mail address 2
Mobile Telephone
What is your field of interest/subspecialty?
Where do you practice? (hospital/university/private; state name and address of your current place of work)
4. What is your experience in clinical research?
5. Do you have a basic knowledge of the principles of
a) clinical trials methodology?
b) clinical pharmacology?
c) statistics?
6. What are your plans for the direction of your future career?
Free Motivation Statement
(Please indicate the reasons why you think this course will be valuable to you in approx 150 words)
Please tell us your idea for a new clinical research project (Title and a short description)
Title
Description

Additional Important Information

Successful candidates will be required to prepare a short talk as an example of clinical research that they are currently undertaking, or have previously carried out. This will be a 6 min presentation with 6 slides to present to the group.

If you have previously attended the European School of Internal Medicine (ESIM),indicate which year you attended.
If you have previously applied to attend the Clinical Research Seminar but not been successful, please state ‘Yes’ in the box.

Your Name (please print):

Date Submitted:

Fondation pour le Développement de la Médecine Interne en Europe

c/o Fiduciaire Verifid SA, rue du Rhône 100, 1204 Genève, Switzerland

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