Type of application* Resident

Name of applicant*

DOB (ddmmyyyy)*

Gender* Male Female

Mailing address:

Institute*

Street*

City*

Zip

Country*

Telephone*

Fax

E-mail*

Resident information:I am a year resident

Terms and conditions of EBO Exchange Programme:

1.  Please visit the EBO website to view the list of EBO accredited centres from which you may apply for an    
exchange (http://ebo-online.org/newsite/committee/residency_exch/exchangecontact.asp). Please note          
that you must select your training centre from this list only and no exceptions apply.

2.  Please note before applying for your grant that you must utilise the exchange within the year 2012 and  
any funding must be claimed before December 31st 2012. 

3.  All teaching in the EBO accredited centres will be, for the most part, free of charge, although this is ultimately at the discretion of the individual centres (eg. Moorfields Eye Hospital). The average cost of accommodation is estimated at €400, and suitable and inexpensive options should be sourced by the grant recipients themselves. Travel expenses will naturally depend on the location of the institutions involved in each exchange. An honorarium of €1000 is available to resident grant recipients to compensate for these expenses, so any additional costs must be absorbed by the candidate unless otherwise negotiated with the Chair of your clinic.

Chair information:

Name of Program Chair of your institution:

E-mail of program Chair:

I understand that I will receive an honorarium to compensate for travelling and living expenses, and that I will be responsible myself for arranging any additional costs.

I agree to give a short written report of my exchange visit to The European Board of Ophthalmology to help it to develop the Exchange Program.