last updated: 13:17 Mon 08 Apr 2013

Apply for Fellowship

Gender First name *

Address *

City *

Office Phone *

Private Phone *

Nationality *

Medical School *

Board Certification *

Specialty training *

Department / Institute *

Last name *

Zip Code *

Country *

Office Fax

Email *

Birthdate *

Year of Graduation *

Year *

Are you engaged in a pratice, teaching or research of Urogenital Radiology? *

Yes No

Do you practice diagnostic imaging and/or intervention in a clinical and/or experimental diagnostic imaging department? *

Yes No

Please list at least 5 scientific (clinical or experimental) papers on urogenital radiologic topics exclusive of case reports, in peer reviewed journals listed in Current Content. The applicant shall be senior author. By senior author is meant first, second, or third author, or last if the authors testify that the applicant has played a substantial part in the work. Books, or chapters in books may be considered.

Sponsoring Fellow Members: Send SUPPORTING LETTERS as hard copy!

Do you devote at least 20% of your time to Urogenital Radiology (clinical and experimental work as well as teaching)? *

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