Application Form to Attend

/ The Foundation for the Development of Internal Medicine in Europe
and
The European Federation of Internal Medicine
CLINICAL RESEARCH SEMINAR, PARIS
8 – 10 July 2013 /

APPLICATION FORM

For The 9th EFIM SEMINAR ON CLINICAL RESEARCH

Dates: Arrive Sunday 7th July 2013

Seminar starts: Monday 8th July to Wednesday 10th July 2013

Venue: La Maison du Poumon, 66 boulevard Saint-Michel,

Jardin du Luxembourg, Paris , France

Deadline for receipt of applications: 15 April 2013

ONLINE APPLICATION IS AVAILABLE AT:

Acceptance criteria:

Young Internists from EFIM member countries, under the age of 35 with a good

understanding of English, and with some current or previous experience of Clinical

Research. (Lectures and Interaction will be in English)

I would like to be considered as a candidate for the EFIM Course on Clinical Research.

I expect to be available to attend for the period 7th to 10th July if my application is successful.

Arrive: Sunday 07.07.2013; Course starts: Monday 08.07.2013; Departure: Wednesday 10.07.2013 (pm)

PLEASE TYPE DETAILS BELOW and send your CV

Family Name : / Gender (M/F):
1st Names: / Date of Birth:
Postal Address:
Country: / Nationality:
E-mail 1:
E-mail 2: / Mobile/Cell (include country code)
Telephone: / Fax: (not essential):
1. What is your field of interest/subspecialty?
2. Where do you practice? (hospital/university/private)
3. Address of your 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 (approx 150 words)

Please tell us the reasons why you think this course will be valuable to you.

Please tell us your idea for a new clinical research project (Title and a short description)

Title:
Description:

Please note: 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:

Include your curriculum vitae (incl. publications)

Closing date for receipt of applications: 15.04.2013

Contact: Mrs Janet Stevens, FDIME Administrator e-mail:

Tel: +44 (0)1273 380670

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