AAPM Exchange Scientist Program
Host Institution Application Form
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To be completed by the Host Institution (in a foreign country)
(or by the Exchange Scientist if so desired, when the visit has already been arranged)
Part I
Host Institution and Address: _____________________________________________________________
_____________________________________________________________________________________
________________________________________________Country:
______________________________
Name of Contact Person: _______________________________ Title:
___________________________
Telephone: Country code: _________ City code: __________Number(s): __________________________
FAX: ____________________________________ email: _____________________________________
Please briefly describe the activities you would like the Exchange Scientist to participate in:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please indicate special requirements such as special knowledge, language other than English etc:
_____________________________________________________________________________________
_____________________________________________________________________________________
How soon do you want the scientist to visit and for how long: ____________________________________
_____________________________________________________________________________________
Part II
If you have already made arrangements with the scientist, please complete the following, otherwise go to part III:
Name of Scientist: ____________________________________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Telephone number: ___________________________________________________________________
Part III
The AAPM Exchange Scientist Program is a volunteer, non-funded program. There is no guarantee that an Exchange Scientist will be found within the time frame requested. All expenses are provided or obtained by the Host Institution and/or the Exchange Scientist. All financial arrangements, if any, are to be made directly between the requesting Host Institution and the Exchange Scientist. Neither the AAPM, its members, nor its officers will assume liability for any damage sustained by the Exchange Scientist and/or the host institution as the result of activity(ies) associated with this exchange program.
Signature for the Host Institution: _________________________________________
Please print name: _____________________________________________________
Title: __________________________________ Date: ______________________________
Please send (e-mail, regular mail, or fax) the completed form to:
Milton K. Woo, PhD
Chairman,
Exchange Scientist Program Subcommittee
Medical Physics Dept.
Odette Cancer Ctr
2075 Bayview Ave
Toronto , ON M4N 3M5
CANADA
e-mail : milton.woo@sunnybrook.ca
Phone : 1-416-480-5853 Fax : 1-416-480-6801
Last update: November 15, 2007