Surname

Applicant number

Assessment
admission
requirement
First round
Decentralized Selection Procedure
2014-2015

Medicine
Global Health
Molecular Medicine

(please mark your choice)

Use Dutch form for:

Tandheelkunde,
Geneeskunde Duurzame Zorg of Intramurale Zorg

This form is accompanied by an instruction guide on how to fill it in.

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Surname

Applicant number

University of Groningen
UMCG

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Applicant number

A. Personal details
Initials

First name

Surname

Date of birth

Place and country of birth

Nationality/nationalities

Gender

male
female

Testimonial
I hereby declare that all of the information provided in this file is true.
I give the coordinator of the University of Groningen/UMCG decentralized selection procedure
permission to contact the references I have mentioned to verify the information I have provided.

Date

Signature

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Applicant number

Prior education: secondary school

B.1 VWO (Dutch pre-university education)

I will take my VWO final exams for the first time this school year.
I have already taken VWO final exams.

go to question C.1
go to question C.3

B.2 NON-VWO (e.g. GCSE, Arbitur, IB, ..)

I follow(ed) a different pre-university education programme.

go to question C.4

C.1 I will take my VWO final exams for the first time this school year
For which VWO diploma will you take final exams this school year?
A diploma that satisfies the entry requirements for the degree
programme in Medicine.
A diploma that does not satisfy the entry requirements for the
degree programme in Medicine.

C.2

complete question
C.2
Go to question C.3.1

Statement concerning VWO final examinations in 2014

The undersigned hereby declares that

___________________________________________________________________
_________________________________________________________________________, student of our school,
will take the national written examination in order to gain a diploma that satisfies the entry
requirements for the degree programme in Medicine in the current school year (2014). This
means that the pupil will at least take examinations in the subjects Physics, Chemistry,
Biology and Mathematics.
Name of school

Name of school counsellor/mentor

Telephone number

Signature

School stamp

Date
Go to section D

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C.3

Applicant number

I have already taken VWO final exams

Final exam
year

Result
(pass/fail*)

Did the final exam satisfy the entry

requirements for the degree programme in
Medicine? (yes/no)

Go to section C.3.1

C.3.1 Do you have a diploma that satisfies the entry requirements for the
degree programme in Medicine?

Yes.
Go to section D
No, but I will have satisfied the entry requirements in another way Go to question C.4
by 1 August 2014.

C.4
I follow(ed) a different pre-university education programme (University)
C.4.1
Please specify your secondary school training

I will take my final secondary school exams this school year for the Go to question C.4.2
first time:

I have previously taken final secondary school exams:

Go to question C.4.2

C.4.2
Final examinations 2014 entry requirements for the degree
programme in Medicine

A diploma that satisfies the entry requirements for the degree

programme in Medicine
in the Netherlands.
A diploma that does NOT satisfy the entry requirements for the
degree programme in
Medicine in the Netherlands.

C.4.3

complete question
C.4.4
and go to section D
complete question
C.4.3
and go to question
C.5

Deficiencies

a. Please specify what applies to you with regard to a deficiency in Biology.

I do not have a deficiency in Biology because:

I will have remedied my deficiency by 1 August 2014.

If this applies to you, you will not be eligible for the decentralized selection procedure and
completing and submitting this form will therefore be pointless.
b. Please specify what applies to you with regard to deficiencies in Physics, Chemistry or
Mathematics.
N.B. You will not be eligible for the decentralized selection procedure if you have deficiencies in
two or more of these subjects. Completing and submitting this form will therefore be pointless.
Physics

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Applicant number

I do not have a deficiency in this subject because:

I will have remedied my deficiency by 1 August 2014 as a result

of:

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Applicant number

Chemistry
I do not have a deficiency in this subject because:

of:

I will have remedied my deficiency by 1 August 2014 as a result

Mathematics
I do not have a deficiency in this subject because:

of:

I will have remedied my deficiency by 1 August 2014 as a result

Go to section C.5

C.4.4

Secondary school statement

The undersigned hereby declares that

_____________________________________________________________________________________________
________________________________________________________________________, student of our school,
will do/did final examinations
________________________________________________________________________,
______________________________________________________________________________________________
This student will take examinations in:
Biology

Yes, at the level of:

Chemistry

Yes, at the level of:

Mathemati
cs

Yes, at the level of:

Physics

Yes, at the level of:

Dutch

Yes, at the level of:

English

Yes, at the level of:

No
No
No
No
No
No

Name of school
Name of school counsellor/mentor

Telephone number

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Signature

Date

Applicant number

School stamp

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C.5 I have taken the following degree programme after secondary school

Yes
No

Go to question C.5.1
Go to question D

C.5.1 I have taken the following degree programme after secondary school
I have taken the following degree programme after secondary school:

Type of programme
University

HBO (university of
applied sciences)

Other, viz.:

Name of educational
institution

Town/city

Name of contact person (school counsellor/study advisor)

Telephone number of contact

person

Academic year(s) of registration

Number of ECTS credit

points earned till 1
February 2014:

Propaedeutic exam

Final degree

Yes
No

Yes
No

Languages

D.1 Native language(s)

Please specify your native language(s).

Go to question D.2

D.2 Other languages

Please specify your other languages.

Go to question D.3

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D.3 Proficiency in English

a. Please specify which of the following statements reflects your
proficiency in English
I am a native speaker.
I have an official letter from my secondary school stating that the
language of instruction is (was) English in all subjects.

I will take my VWO final exams this school year and I have received
a final mark of 8.0 or higher in year 5 of VWO for English.

I have already taken my VWO exams and I have scored an 8.0 or

higher on my VWO exam on the subject of English.

I passed a computer TOEFL.

I passed a paper TOEFL.
I passed an internet TOEFL.
I passed an IELTS Academic British Councils English Language Test.
I obtained a CPE (Cambridge Certificate of Proficiency in English).
I obtained a CAE (Cambridge Certificate of Advanced English).

I will be taking the following test,

______________________________________(name) on
___________________________________________ (date) and I will submit the
document stating my test result before
___________________________________ (date).
b. What was your mark for English in your final secondary school exam?
N.B. If you are taking your final exams in 2014 please state your final
mark for English received in year 5.
Mark

Marking scale (e.g.1-10)

Go to section E

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E. Checklist Assessment admission requirement*

* If you do not meet the entry requirements it is pointless to complete and summit this
application test form. In case of doubt, contact cbt@umcg.nl.
Please check if you have included all appendices for part I of the application test.
Compulsory appendices for VWO-candidates:
1. Copy of your passport/ID
2. A list of your final marks from previous year (from VWO 5, admitting you to VWO 6, or
equivalent).
3. If applicable: Statements about all deficiencies you still need to remedy. Enclose certified
photocopies of certificates or diplomas and the accompanying lists of marks for all remedied
deficiencies.
4. If applicable: Certified photocopies plus the accompanying lists of marks of all diplomas you
have gained.
5. If applicable: A certified list of study results.
Compulsory appendices for candidates who followed a degree programme after secondary
school:
1. Copy of your passport
2. A certified list of study results
3. Proof of proficiency in English: certified photocopies of the certificates or diplomas and the
accompanying lists of marks or the letter from your secondary school. Also make sure that
your mark for English (D.3.b) is stated on the documentary evidence.
Compulsory appendices for candidates who follow(ed) a different pre-university education
programme (University)
1. Copy of your passport
2. If applicable: A list of your final marks (from VWO 5, admitting you to VWO 6, or equivalent)
3. Certified photocopies plus the accompanying lists of marks of all diplomas you have gained.
4. If applicable: Statements about all deficiencies you still need to remedy. Enclose certified
photocopies of certificates or diplomas and the accompanying lists of marks for all remedied
deficiencies.
5. If applicable: A certified list of study results.
6. Proof of proficiency in English: certified photocopies of the certificates or diplomas and the
accompanying lists of marks or the letter from your secondary school. Also make sure that
your mark for English (D.3.b) is stated on the documentary evidence.
Bring the completed form and the required appendices to the first selection round on
22 February 2014.
Please present your file in a neat manner.

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Surname

Applicant number

Application test
First round
Decentralized Selection Procedure
2014-2015

This form is accompanied by an instruction guide on how to fill it in.

University of Groningen
UMCG

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Average marks

F.1 Average marks Biology, Chemistry, Mathematics, Physics, Dutch, English

Please, fill in your average marks of VWO 5, admitting you to VWO 6, or equivalent for Biology,
Chemistry, Mathematics, Physics, Dutch and English. If you did your final exam before, please fill
in your final marks as well.
Subject

Average marks of VWO 5, admitting Marks final exams

you to
VWO 6, or equivalent

Biology
Chemistry
Mathematics
Physics
Dutch
English

G Outstanding achievement
I have accomplished the following outstanding achievement:

Scope
National
Period of activity:
From:

European
Until:

Average number of hours per week:

Description of the effort required for this achievement:

Global

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Assignments

H.1 Curriculum Vitae

Please provide a clear and complete curriculum vitae and add this as appendix H.1.

H.2 Motivate with 3 aspects why you have chosen for your study.
Write a report with a maximum of 200 words. Add the report as appendix H.2.
H.3 Preparatory assignment 1
Find two articles (in English or Dutch) from the national or international media. Ideally they should
be background articles from newspapers or magazines, written for a general, well-informed target
group, dating back no more than 6 months and discussing topics that you consider typical for your
preferred learning community.
Write a 300-word report based on these articles, summarizing the themes/problems discussed in
the articles, indicating their relevance and discussing which related academic research you would
like to conduct within the context of your learning community.
Please bring to the selection day: 2 articles and 1 report
H.4 Preparatory assignment 2
Read the enclosed article Soft drinks making Mexican children the fattest in the world. A number
of questions will be asked about this article during the selection day in February.
H.5 Preparatory assignment 3
Ask four people who know you well to write a 300-word statement why you would make a good
doctor. Also ask your respondents to state at least one reason why you might need to reconsider
your career choice.
Each respondent should endorse their statement with their name, signature and telephone
number.
Please bring to the selection day and add to as appendix H.5: 4 signed statements.
H.6 Preparation for written test
Prepare for a written test by studying the following homework.
The homework consists of:
1. Chapter 25 of Principles of mucosal immunology about viral infections, mainly focused on
two important mucosal viral infections, rotavirus and HIV.
2. HIV vaccine development at turn of the 21st century, by M.P. Girard and S.A. Plotkin, Current
Opinion HIV AIDS 2012, 7:4-9
3. Periodontal disease in HIV/AIDS, by M.I. Ryder, W. Nittayananta, M. Coogan, D. Greenspan
and J.S. Greenspan, Periodontology 2000, 2012, 60:78-97
4. Video: http://education-portal.com/academy/lesson/classification-of-viruses-viral-genomeand-replication-scheme.html

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I.

Applicant number

Checklist application test

Please check if you have included all appendices for part II of the application test.
Compulsory appendices:
1. If applicable: the appendices for sections G
2. H.1. Curriculum Vitae
3. H.2. Motivation
4. Preparatory assignment H.3 en H.5
Enclose all the appendices in your file and bring it with you to the first selection
round on 22 February 2014.
Please present your file in a neat manner.