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PUMCH International Students Exchange Program Application Form
CopyFrom: PUMCH UpdateTime: 2017-12-21 Hits: 164 Font Size: SmallBig

Personal Information

Family name(as written in passport)

First name(as written in passport)

Sex

Date of birth(dd/mm/yyyy)

Nationality

Language spoken(native, excellent, good or fair)

Passport number

Passport valid till(dd/mm/yyyy)


Enrollment Information

Medical School

Medical student since

Clinical student since

Expected day of graduation


Mailing and Electronic Information

Street &Number

City

Post Code

Country

Home Phone Number

Cellular Number

Email

Alternative Email


Exchange Preferences

1st Desired Department

2nd Desired Department

3rd Desired Department

4th Desired Department


Exchange Details

Exchange Start Date(dd/mm/yyyy)

Exchange End Date(dd/mm/yyyy)

Do you need an official invitation letter?(for visa or other purpose)

Will you have insurance coveragefor the exchange period?

Would like to be placed togetherwith this student


Student Remarks

Space for notes/messages to elective officer