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
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