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INTERNATIONAL FEDERATION OF MEDICAL STUDENTS‘ ASSOCIATIONS STANDING COMMITTEE ON PROFESSIONAL EXCHANGE

APPLICATION FORM

Please use a typewriter or capital letters

Application issued by:

Family name

First name

STAMP NORE SIGNATURE

Nationality

Passport number

Expiry date

Date of birth

Sex

 male

 female

Medical student since

day month year

Clinical student since

Medical school

Expected date of graduation

Native Language

Other Languages

Mailing Address of Exchange Student:

Street

City

Postal code

Country

Phone

Fax

E-mail

country code area code number

country code area code number

Desired Country

1^st choice

2^nd choice

3^rd choice

City 1.

City 1.

City 1.

2.

2.

2.

3.

3.

3.

Desired Department

Field Studied

Exam Passed

Field Studied

Exam Passed

1.

3.

2.

4.

Desired duration and period : Duration in weeks ___________ within the period from _____________ to _____________
Desired type of clerkship Preclinical Clinical
If possible, I would be like to be placed together with:__________________________________
I have a health insurance coverage for this period	 yes	 no
I need an invitation letter (for visa or other purposes)  yes  no
Applicant’s signature			Date