Educational fellowship application form - British Division of the International Academy of Pathology

Please complete the online form below and then ask your head of department to complete Form B which can be downloaded by clicking here and ask the HOD email that form to Sam Keily, BDIAP Administrator

Name:*

First

Last

Professional address:*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone:*

Area Code

Phone Number

E-mail:*

Present position:*

Institution where the award would be held:*

Address of the institution:*

Name of the individual(s) to be visited:*

Description of the educational aspect to be studied:*

Please state briefly why you have chosen this centre:*

Please describe how this visit will benefit your education and those in your home department:*

Starting date of visit:*

Finishing date of visit:*

Length of visit (months):*

Travel cost (£):*

Travel date:*

Travel method:*

Travel class:*

Subsistence cost (£):*

Number of days subsistence:*

Laboratory expenses (£):*

Laboratory expenses details:

Total amount requested (£):*

Name and address of current head of department who will complete form B and send it in:*

I understand that my data will be stored by the BDIAP and I may be contacted in the future by the BDIAP on matters relating to my membership. This data will be stored in accordance with the BDIAP's data privacy policies and will not be released to third parties. I may request that my data is deleted at any time using the data deletion request form in the data privacy policies section of the website however I understand that my data is stored as a contractural necessity of my membership of the BDIAP so that if I ask for my data to be deleted this will also mean that I am cancelling my membership.*