International Observership Application - Cure Glaucoma Foundation

Contact Information

^* required fields

Name*

First Name*

Middle Name*

Last Name*

Gender

Date of Birth*

Email*

Skype Name

Phone (Include Country Code)*

Address*

Street Address

City

State / Province / Region

ZIP / Postal Code

Country/ Province / Region

Home Country (If not a United States citizen)

Languages*

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Email*

Street Address

City

State / Province / Region

ZIP / Postal Code

Country

Education

Describe your Education and any Honors

Ophthalmology Related Volunteer Work

Please describe any ophthalmology related volunteer work including the institution and dates of service.*

Observership Questionnaire

Describe what knowledge and skills you wish to acquire.

What do you want to be able to do with what you learn? What are the practical implications of this observership on your professional development?*

Please explain your plans after you return to your home country and for the future. How will you help your institution, your country? How will you enhance eye care and education in your country?*

Application Support Documents

Scanned Copy of Passport

Scanned Copy of Certificate, Diploma, or equivalent

Letter of Recommendation

Professional References (3)*

Record of Immunization

Personal Statement

Curriculum Vitae (CV)

For submission by mail, fax or email please send this International Observership Application to:

Cure Glaucoma Foundation
Attn: International Observerships
10740 N. Central Expressway, Suite 300,
Dallas, TX 75231
(214) 765-9716 Voice
(214) 360-0083 Fax
admin@CureGlaucoma.org