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:
Address:
E-mail:
*
Program(s) applying to (Check the box of any program for which you want to be considered. Then rank selection in order from most preferred to least preferred [1 is most preferred; 2 is second preference; etc., through 6]; if you do not wish to be considered for a particular program, please do not check the box and do not enter a ranking.)
Phone Number:
Argentina
Preference
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6
Brazil (Recife)
Please Select
Preference
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6
Brazil (Rio/Sao Paolo)
Preference
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6
Ghana
Preference
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Tanzania
Preference
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Thailand
Preference
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6
Provide a short summary of your teaching experience (200 words maximum):
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")
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.)
Upload a short CV:
Preferred dates for the Professorship (a date range is acceptable):
Duration (a range of durations in acceptable):
Submit
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