EUROPEAN BOARD OF SURGERY
Union Européenne des Médecins Spécialistes
European Union of Medical Specialists
EBSQ GENERAL SURGERY EXAMINATION - APPLICATION FORM
FAMILY NAME (as on passport) ……………………………………………………………………………………………………………………
FIRST NAMES (as on passport) …………………………………………………………………………..…………………………………………..
NATIONALITY …………………………………………..
DATE/PLACE OF BIRTH …………………………………………..
ADDRESS FOR CORRESPONDENCE:
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TELEPHONE ………………………………………………………... FAX …………………………………..
Email address ……………………………………………………………………….
PRESENT APPOINTMENT:
TITLE ………………………………………………………………………………………………………….………………………………………………………
DEPARTMENT …………………………………………………………………………………………………………….…………………………………………….……..
ADDRESS ……………………………………………………………………………………………………………………………………….…………………………
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DECLARATION BY REFEREE 1 (Current training tutor, Head of Department or Clinical Director)
I have had direct knowledge of the applicant during the training or work period. I declare that to the best of my
knowledge the information provided by the candidate concerning his/her training experience is correct.
SIGNATURE …………………………………….………………………..
PRINT NAME ………………………………………………………….............................……… DATE………………………..……
POST HELD and HOSPITAL ADDRESS ……………………………………………….……….
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PROFESSIONAL EMAIL ADDRESS …………………………………….……………………….
MOBILE TELEPHONE NUMBER …………………………………….……………………….
Application form April 2021
EUROPEAN BOARD OF SURGERY
Union Européenne des Médecins Spécialistes
European Union of Medical Specialists
DECLARATION BY REFEREE 2 (Consultant surgeon of the applicant’s choice)
I have direct knowledge of the applicant and I declare that to the best of my knowledge the information provided
by the candidate is correct.
SIGNATURE …………………………………….………………………..
PRINT NAME ………………………………………………………….............................……… DATE………………………..……
POST HELD and HOSPITAL ADDRESS ……………………………………………….……….
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PROFESSIONAL EMAIL ADDRESS …………………………………….……………………….
MOBILE TELEPHONE NUMBER …………………………………….……………………….
DOCUMENTS check-list for application
See Guidance under the Eligibility section.
Requirements Tick if provided
1 Present application form signed by candidate and two referees
2 Curriculum Vitae (template provided)
3 Certificate of Primary Medical Qualification
4 Evidence of 6 years of surgical training
5 Medical Registration Certificate
6 Proof of identity
7 Surgical logbook (template provided)
8 Evidence of 25 credit points in CME and/or publications
9 2 recommendation forms (template provided)
10 Payment of eligibility process fee
DECLARATION BY APPLICANT
I wish to apply for Eligibility to sit the UEMS European Board of Surgery Qualification (EBSQ) General Surgery Examination,
based upon assessment of my surgical experience. I declare that all information provided in support of my application is
correct.
Application form Nov 2018
EUROPEAN BOARD OF SURGERY
Union Européenne des Médecins Spécialistes
European Union of Medical Specialists
SIGNATURE ………………………………………………………..…..……. DATE…………………………….
Application form Nov 2018
