APPLICATION FOR ACCREDITATION OF
FELLOWSHIP IN SPINAL SURGERY

Fellowship details

* Type of fellowship

Clinical Research

Laboratory Research

Other Research

* Proposed start date

* Duration of fellowship

Six months One year

* Are you CPD compliant?	Yes No
* Upload your CPD certificate

Please nominate estimated time allocations in the following areas:
Surgery
Consultations
Clinics
Laboratory or clinical research
Teaching
Meetings
Audit
Self-directed learning

Company name
Amount of stipend
Does the company abide by the MTAA code of conduct or its equivalent?	Yes No

International fellowship fund?

Yes No

Assistant required?	Yes No
Amount

On-call income?	Yes No
Amount

5. Other Sources of funding?
Do the supervisors agree to abide by the AOA Code of Conduct for Interaction with Medical Industry?	Yes No

* Chief supervisor's name
Attach detailed, current curriculum vitae

* Address for correspondence
* Address 1
Address 2
* Suburb
* State
* Postcode
* Country
* Email
* Phone
* Fax

I agree with AOA membership application terms and conditions.