APPLICATION FORM

ESGO Advanced Course in

Ovarian Cancer Surgery

March 22 – 24, 2018

Hamburg, Germany

PARTICIPANT’S DETAILS

Family name: First name:

Gender: Male / Female: Age:

Institution:

Position:

Country:

Mobile No. (with country code):

Email:

I am currently an ESGO member with paid membership fee 2018

ESGO membership for 2018 is a mandatory condition for attendance.

The course is limited to 21 attendees. The official course language is English.

The ideal profile is experienced gynaecological oncologists looking to improve their handling of complex oncological cases. Applications will be treated on a first come, first served basis with respect to geographical balance of countries and regions as well as level of experience judged by the committee according to the Brief description of professional background provided to the jury. Successful candidates will be notified by February 4, 2018.

Course package fee: 868 EUR (all taxes included) to be paid by accepted candidate.

Fee includes: • Course admission, •Accommodation for 2 nights in a single room •Coffee breaks, lunches, networking event, • Transfer from the hotel to the venue

Hotel accommodation for 2 nights (March 22-24, 2018) will be included in the course package fee. If extra night is needed, it can be arranged by ESGO, but will be paid by attendees in addition to the course package fee.

Interested gynae-oncologists should apply by returning the following documents to :

1.  Filled in Application form

2.  Letter describing motivation for attending the course

3.  Short Curriculum vitae

The deadline for sending the form is by January 14, 2018. Successful candidates will be notified by February 4, 2018. The reservation can only be confirmed upon receipt of the course package fee payment. If the fee is not received by February 19, 2018, the position will be offered to the next suitable applicant. In case of cancellation without replacement, 50% of the course package fee will be refunded, only if a written request is provided and received by March 1, 2018. No refund can be made if the notice of cancellation is received after this date or in case of no-show.

By submitting this Application, you agree with the cancellation conditions and give permission to ESGO to take photographs/video/sound recordings of you, captured during the meeting and used in printed and electronic media, including the internet, for teaching and research/promotional purposes.

Signature Date:

ESGO gratefully acknowledges Ethicon for a generous educational grant supporting this course

ESGO Office, Palace YMCA, Na Porici 12/1041, 110 00 Prague, Czech Republic,

Tel: + 420721271 485 | Email: adminoffice@esgomail.org | www.esgo.org