International Fellowship Application

Contact Information

Name*

First Middle Last

Gender

Date of Birth*

Email*

Skype Name

Phone (Include Country Code)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Country (If not a United States citizen)

US Visa Status*

Languages*

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Email*

Emergency Contact Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please check one of the following statements*

I wish to apply for funding for travel costs and travel expenses.
I wish to apply for an unfunded fellowship. I will be responsible for my own living and travel expenses.

Education

Institution Name*

Location*

Years Attended*

Fellowship Training

Institution Name*

Location*

Years Attended*

Licenses/Certifications*

Ophthalmology Work Experience

Practice Names and Locations*

Fellowship 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 fellowship 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?*

Research Experience*

Honors/Awards*

References

List a minimum of 3 with Contact Information (Institution names, addresses and phone numbers)*

Application Support Documents

Scanned Copy of Passport

Scanned Copy of Certificate, Diploma, or equivalent

Letter of Recommendation

Record of Immunization

Personal Statement

Curriculum Vitae (CV)

For Submission By Mail, Fax or Email

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

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

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Contact Information

Emergency Contact Information

Education

Fellowship Training

Ophthalmology Work Experience

Fellowship Questionnaire

References

Application Support Documents

For Submission By Mail, Fax or Email

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

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Contact Information

Emergency Contact Information

Education

Fellowship Training

Ophthalmology Work Experience

Fellowship Questionnaire

References

Application Support Documents

For Submission By Mail, Fax or Email

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

Sign up for our
E-Newsletter