APPLICATION AS HOST
Name of institution
*
Address of institution
*
Street
Straße und Hausnummer (zweite Zeile)
City
Bundesland
Zip Code
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Afghanistan
Albania
Algeria
American Samoa
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Angola
Anguilla
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Austria
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The Bahamas
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The Gambia
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Iran
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Jamaica
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Jordan
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Laos
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Lebanon
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Libya
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Lithuania
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Malawi
Malaysia
Maldives
Mali
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Moldova
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Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Turkish Republic of Northern Cyprus
Northern Mariana
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Oman
Pakistan
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Palestine
Panama
Papua New Guinea
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Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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Sri Lanka
Sudan
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Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Tuvalu
Uganda
Ukraine
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
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Country
Website
*
Specialty focus / Areas of particular expertise
*
Name of contact person
*
First name
Last name
E-Mail
*
example@example.com
Type of accommodation
*
e.g. Hotel, Hostel, Private, etc.
Accomodation can be provided for free.
*
Yes
No
Duration accommodation can be provided (up to 2 weeks)
*
Number of operations at the institution per week
*
Number of residents
*
Number of attendings
*
Potential to scrub in (yes/no)
*
Bitte auswählen
Yes
No
Requirements to be allowed to scrub in:
Reasons for seeking a Fellowship at this institution (200 words)
*
Submit
Should be Empty: