ESCP Presentation masterclass application form
Name
*
First Name
Last Name
Email address
*
example@example.com
Gender
*
Male
Female
Non-binary
Prefer not to say
Age range
*
25-35
35-45
45-55
55-65
>65
Country
*
What type of ESCP Membership do you have?
*
Full
Trainee
Online
Affiliate
U-35
I am not a member of ESCP
Position
*
Consultant
Fellow
Resident
Other
Briefly describe your clinical practice (75 words maximum)
*
0/75
Motivation and reasons for application (75 words maximum)
*
0/75
Main contributions to coloproctology (75 words maximum)
*
0/75
Briefly describe your professional leadership contributions:
A. Local or institutional (75 words maximum)
*
0/75
B. Society, college (75 words maximum)
*
0/75
C. Committee leadership (75 words maximum)
*
0/75
D. Committee membership (75 words maximum)
*
0/75
Describe your community leadership contributions (75 words maximum)
*
0/75
Briefly describe your professional leadership contributions:
A. Candidate’s current h-index in Web of Science
*
B. Date of the most recent peer-reviewed publication
*
-
Month
-
Day
Year
Date
C. Top 5 publications and explain your rationale (max. 3 sentences/publication)
*
D. Total number of papers on Medline / PubMed
*
If you are selected for this opportunity, how will it impact on your career and clinical practice? (75 words maximum)
*
0/75
Were there any events, family or personal challenges that may have impacted on your career? (optional)
SUBMIT
Should be Empty: