PHOTO

INTERNATIONAL FEDERATION

OF MEDICAL STUDENTS‘ ASSOCIATIONS

 

STANDING COMMITTEE ON RESEARCH EXCHANGE

 

 

APPLICATION FORM

Please use 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

 
Students’ address:

Street

 

City

 

Postal code

 

Country

 

Phone

 

Fax

 

E-mail

country code                    area code                      number

 

country code                    area code                      number

 

Languages spoken

 
Desired country

native language

other languages

1st choice

Project name

 

 

 

 

 

Department

 

City

 

 

 

 

 

# of weeks

 

from

 

till

 

2nd choice

Project name

 

 

 

 

 

Department

 

City

 

 

 

 

 

# of weeks

 

from

 

till

 

3rd choice

Project name

 

 

 

 

 

Department

 

City

 

 

 

 

 

# of weeks

 

from

 

till

 

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