Fellowship Program FormFellowship Program Form If you are human, leave this field blank. Fellowship Title If Neuroimmunology, which of the following is covered: Choose all that apply. Demyelinating diseases (MS, NMO, etc.) Neuro-rheumatology Paraneoplastic Encephalitis Peripheral Neuroimmunology Vasculitis Autoimmune epilepsyThe fellowship training track is: Clinical (percentage) Research (percentage) Fellowship duration is: (in years) How many fellows per year? Do fellows take call duty? Yes No OtherOther Does the fellowship have general neurology clinics? Yes No Our fellow perform rotations in (check all that apply): Neuropathology Neuro-Ophthalmology Neuro-Urology Neuro-Radiology Electrophysiology Neuro-Rehabilitation Neuropsychology Visa sponsorship Yes No What type of Visa? J1 H1B Is the fellowship approved by the GME office? Yes No Does the fellow need to secure additional funding? Yes No Is there a deadline for the application? Yes No What is the deadline for the application? Link to the fellowship website: Contact Information Completed by: Name and credentials of the contact person/s: Name of the institution: Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country Email Address Phone Number reCAPTCHA Submit
