Name: __________________________________________________________________

Address: _________________________________________________________________

              _________________________________________________________________

Telephone:
Home ___________________  Office __________________  Cell ____________________

E-mail: ______________________________  Degree:_____________________________

Current Position: ______________________________   Since: ______________________

Specialty:

Andrology

Basic Research

Embryology

OB/GYN

Urology

Other

Previous experience in related area: _____________________________________________

              _________________________________________________________________

Interest:

Module 1	Module 1A	Module 1B	Module 2	Module 3	Module 4
Module 5A	Module 5B	Module 5C	Module 5D	Module 6	Module 7
Module 8	Customized Modules: _______________________________________

Training Objective: ________________________________________________________

              ________________________________________________________________

              ________________________________________________________________

When are you available for training? ___________________________________________

What is the length of training required? _________________________________________

Note:

• Please see the application procedure and fee schedule for further requirements and instructions.
• This document may be downloaded in PDF form by clicking on the link below
  PDF for Download

FEE SCHEDULE (Effective October 1, 2007)

Module	Training In	Duration	Course Fee (US)
1	Semenology	1 week	$ 3,500.00
1A	Routine Semen Analysis	1 day	$   795.00
1B	Sperm Morphology	2 days	$   950.00
2	Advanced Sperm Function Tests	4 days	$ 3,750.00
3	Sperm Preparation Techniques	2 days	$ 1,750.00
4	Cryopreservation	1 day	$ 1,500.00
5A	Assisted Reproduction (ICSI)	2 weeks	$ 6,750.00
5B	Assisted Reproduction (ICSI)	1 week	$ 4,850.00
5C	Assisted Reproduction (ICSI)	1 week	$ 5,750.00
5D	Assisted Reproduction (ICSI)	Selected by the Candidate	To be determined
6	Vitrification	1 Day	$ 2,000.00
7	Management of Lab	2 Days	$ 2,500.00
8	Preparing for Accreditation	2 Days	$ 2,500.00

• Clinical rotation in an IVF laboratory is optional. Fee is based on the number of days spent. Contact us for the clinical rotation charges.
   
• Fees must be paid in full, 8 weeks in advance by a Certified Bank Check made out to the "Andrology Lab Research Program".
   
  Please mail your check to:
  Program Director
  Center for Reproductive Medicine &
  Andrology Laboratory
  Glickman Urological & Kidney Institute
  The Cleveland Clinic
  9500 Euclid Avenue, Desk A19.1
  Cleveland, Ohio 44195, USA
   
• Fees can also be paid by Wire Transfer. (Please click here for instructions.)
   
• Please note that there is no discount for multiple training modules (e.g., Modules 1, 2, 3 = $9,000.00 and will last 2 weeks).
   
• Refunds of 50% of course fees may be allowed if requests are received in writing up to 4 weeks prior to the scheduled training. No refunds will be issued if made after that time.
   
• Please click on the links below to review hotel/ housing availability near the Cleveland Clinic:
   
  o Affordable apartments near the Cleveland Clinic
   
  o Moderately priced hotels and inns near the Cleveland Clinic
   
  o Cleveland Clinic group of Hotels and Guesthouse