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2015 Annual Meeting of the
Eastern Vascular Society
MOCK ORAL BOARD EXAMINATION
REGISTRATION FORM
ATTENDEE INFORMATION (please print)
Name
Program
Program Director
Year in Residency
Address
City
State/Province
Country
Phone
Fax
Postal Code
Email Address (required for confirmation)
All fields above are REQUIRED to process your registration.
REGISTRATION FEES
BEFORE
August 25
BEGINNING
August 25
$50
$100
Complimentary
Complimentary
Amount
MOCK ORAL EXAMINATION
PRE REGISTRATION REQUIRED
Thursday, September 24, 2015 at 7:00 am
Active Member
Vascular Fellow/Senior Vascular Resident *
TOTAL ENCLOSED
__________
__________
$___________
* Must Provide a Signed Letter from Residency Director
□
□
□
□
Name (As it appears on Card) _____________________________________________________ Security Code: _____________
(See card images above)
CREDIT CARD NUMBER: ___________________________________________________________________________________
EXPIRATION DATE: ____ /_____
BILLING ADDRESS_______________________________________________________________________________________
(If not the same as address listed above)
SIGNATURE: ____________________________________________________________________________________________
I authorize EVS to charge my credit card the above fees
PLEASE NOTE: This form only registers you for the Mock Oral Board Examination. To register for the 2015
Annual Meeting and/or the Young Surgeon’s Program, you MUST complete the 2015 Annual Meeting Registration
Form.
PLEASE SEND THIS REGISTRATION FORM TO:
EVS Administrative Office
500 Cummings Center, Suite 4550 ‖ Beverly, Massachusetts 01915
Telephone: 978.927.8330 ‖ Fax: 978.524.0461
2015 Annual Meeting of the Eastern Vascular Society
Mock Oral Board Examinations Scholarship
The Eastern Vascular Society has established a scholarship to encourage vascular
residents and fellows to participate in the Mock Oral Boards. The exams will be given
on September 24, 2015 at the Hyatt Regency Baltimore in Baltimore, MD as part of
the 2015 Annual Meeting. The scholarship awards will be given to vascular fellows
and senior vascular residents (PGY 4 & 5) to defray the cost of travel and lodging.
Eligibility and Notification
Vascular fellows and senior vascular residents (PGY 4 & 5) who are enrolled in one of
the accredited programs in the Eastern United States and Canada are encouraged to
apply for the scholarship. Applications must be received no later than Tuesday,
August 25, 2015. Notification will be sent to accepted individuals via e-mail.
Application
To apply, vascular fellows and residents should fill out and submit the application form.
All applications for the Mock Oral Board Scholarship Program must be received by
Tuesday, August 25, 2015.
Mock Oral Board Details
The Mock Oral Boards will be held on Thursday, September 24, 2015 from 7:00 am10:00 am. Each participant will go through 2 testing sessions. In each testing session,
there will be two examiners who will alternate presenting clinical scenarios. At the end of
the exam the fellow or resident will receive a score and feedback from the examiners.
Expense Reimbursement
A reimbursement check will be provided after the Annual Meeting and upon receipt of
the appropriate receipts. Reimbursement will be up to $1,000 in travel expenses to
cover air travel (economy only), mileage, parking, tolls, and hotel accommodations.
Local residents will be reimbursed for parking.
This Scholarship was made possible through an educational grant from
W.L. Gore & Associates Inc.
APPLICATION for the 2015 Annual Meeting of the Eastern Vascular
Society
MOCK ORAL BOARD E X A M I N A T I O N S SCHOLARSHIP
Applicant’s Information (please print clearly)
First Name
Last Name
Institution
Institution Mailing Address
Daytime Phone Number
Cell Phone
Email Address
Please check one of the following:
□ Vascular Fellow, 1st year
□ Vascular Fellow, 2nd year
□ None of the Above
□ Vascular Surgery Resident, 4th year
□ Vascular Surgery Resident, 5th year
APPLICATION DEADLINE: Tuesday, August 25, 2015
PLEASE SEND THIS SCHOLARSHIP FORM TO:
EVS Administrative Office
500 Cummings Center, Suite 4550‖ Beverly, Massachusetts 01915
Telephone: 978.927.8330‖ Fax: 978.524.0461