International Outreach Professor Host Country Application

Anne G. Osborn ASNR International Outreach Professorship Application

This form is to be completed by the ASNR member interested in participating in the program. Please attach a short CV with this form.

Name(Required)

First Last

Address

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

Email(Required)

Phone(Required)

Programs Applying To: Please rank your selections in order from most preferred to least preferred [1 is most preferred; 2 is second preference; etc.] for all programs you wish to be considered for. If you do not wish to apply for a certain program, please leave it blank.(Required)

Argentina

Brazil (Recife)

Brazil (Rio/Sal Paolo)

Colombia

Ethiopia

Ghana

South Africa

Tanzania

Provide a short summary of your teaching experience (200 words maximum):(Required)

Areas of Expertise Examples: Brain, Spine, Skull Base, Orbit, Head & Neck, Diagnostic, Interventional, Adult, Pediatric, etc. (you may list more than one "area of expertise")(Required)

Lecture Topics/Titles. ( List at least 6 different lectures which can deliver during your professorship. A longer list is acceptable. The host organization will choose approximately 4-5 topics from your list.)(Required)

Upload a Short CV(Required)

Max. file size: 50 MB.

Preferred dates for the Professorship (a date range is acceptable):(Required)

Duration (a range of durations in acceptable):(Required)

Anne G. Osborn ASNR International Outreach Professorship Application

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