Fellowship Proposal Form

Fellowship proposal form

Candidate’s Details

Last Name:

First & Middle Name:

ISN LM No:

Date of birth (dd/mm/yy):

Age

Candidate’s work address

Candidate’s Email Address:

Honours & Degrees:

Other Fellowships/ memberships:

Principal Appointment:

Date of Qualification (dd/mm/yy):

Current Appointment Since (dd/mm/yy):

Proposer’s Details

Name of Proposer:

Title :

ISN LM No:

Working Relationship With Candidate:

Proposer’s Correspondence Address:

Proposer’s Email Address:

I declare that I know the candidate and that the information presented herein is accurate, and reliable. I am not aware of any disciplinary, professional conduct, or ongoing performance issues that might affect the candidate’s suitability as a fellow.

The ISN Credentials Committee will judge proposals on the basis of a common set of criteria. It is therefore helpful if you can present information on the candidate by completing the appropriate sections. Not all criteria will, or need to be met in every proposal, so please feel free to complete only the applicable sections.

How has the candidate made significant impact on the service and practice of Nephrology or medicine?

How has the candidate made an out of the ordinary contribution to education of Nephrology?

How has the candidate contributed to the advance of Nephrology by research?

Fellowship Proposal Form

Fellowship Proposal Form

Candidate’s Details

Proposer’s Details

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