PUMCH International Students Exchange Program Application Form
CopyFrom: PUMCH UpdateTime: 2018-01-06 Hits: 601 Font Size: SmallBig

Personal Information
Family name(as written in passport) 
First name(as written in passport) 
Date of birth(dd/mm/yyyy) 
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 
Post Code 
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 

Attachment : PUMCH International Students Exchange Program Application Form