International Visiting Observer Application Form

Stanford Surgery Global Engagement Program

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First (given) name:

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Last (family) name:

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Date of birth:
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Occupation
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Highest Academic Degree *

What is the name of your current institution/hospital?

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In what country is your current institution located? 
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In what city is your current institution located?

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What is your preferred phone number starting with country code?

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What is your email address?

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What is your current mailing address?

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What specialty/specialties are you interested in observing
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Required
Please note specific area in the specialty above that you are most interested in observing:
Please list your first, second, and third choices for which Stanford Surgery faculty would be an appropriate host for your visit:

Have you made contact or discussed your interest in an observership with any of the above faculty members?

Clear selection

Do you need an invitation letter?

Clear selection
Why did you choose to visit Stanford? 

Briefly explain how the observership would benefit your practice and/or training? 

Please note any additional areas of Stanford would you like to see while you are here?

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Required

Requested start date (at least 8-10 weeks after submitting the application):

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Requested end date (maximum 30 consecutive days):

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Do you have an active visa for the USA? 

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Do you need housing/ lodging recommendations?

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I confirm that I have, or can obtain the following required documents:

(email them to kadhim2@stanford.edu )

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Required
Upon completion, I will provide a brief feedback about my experience throughout the observership at Stanford Surgery to the program manager (email kadhim2@stanford.edu). 
Attestation: *
Required
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