APPLICATION FORM
Nationality Indonesia
STAMP
Passport number B 0715371 Expiry date 1 April 2020 NORE SIGNATURE
Medical school,
Country of study Universitas Andalas, Indonesia
Student’s address:
Countr
y Indonesia
Mobile
Phone +6287893632930 phone
country code area code number country code area code number
Languages
spoken Indonesian English
Department City
Project
2nd choice name
Department City
This application form must be accompanied by all the documents stated in the SCORE database.
Project
3rd choice name
Department City
I will obtain insurance coverage for the Research Exchange period. Otherwise my exchange will be
cancelled.
Applicant’s
signature Date 24 October 2017
Education
-Medical Studies :
Name of University, City, Country : Andalas University, Padang, Indonesia
Medical Student since : 15 August 2016 Clinical Student since :
I have completed _1__ years of my __3.5__ year long course.
This application form must be accompanied by all the documents stated in the SCORE database.
studied
Biochemistry
Biology and Genetics
Histology
Anatomy
Physiology
Psychology/Sociology
Microbiology
Immunology
Pharmacology
Pathology
Epidemiology
Internal Medicine :
Cardiology :
Endocrinology :
Dermatology :
Haematology :
Nephrology :
Infectious Diseases :
Neurology :
Pneumology
Oncology
General Surgery :
Orthopaedics and Traumatology :
Ophthalmology
Othorinolaringoiatric
Obstetrics and Gynaecology :
Paediatrics :
Radiology :
Anaesthesiology and Intensive Care :
Forensic Medicine :
Psychiatry :
Others (if you have studied more subjects you do no find on the list
above, please fill spaces below and check them)
_____________________ ð
_____________________ ð
_____________________ ð
Students following an integrated medical degree programme not applying at all with the list above, can send a copy of their
Curriculum Studi, together with this CV.
-Laboratory or Clinical Electives (in native country or abroad) :
etc... (reapeat the scheme above for every Laboratory or Clinical Electives you did)
-Other Educational Activities (Lectures, Conferences, Summer Schools, Medical Courses, etc…)
-
-
-
-Languages Spoken
This application form must be accompanied by all the documents stated in the SCORE database.
Language : Level : Basic Sufficient Excellent
Language : Level : Basic Sufficient Excellent
Employment History:
(e.g. Part Time Jobs)
-
-
-
Social Skills:
(e.g. Voluntary Work)
- Free Medical Check Up
- Circumcision
- Community service
Technical Skills:
(e.g. Computer Skills)
Hobbies / Interests :
(e.g. Playing a Musical Instrument, Painting or Playing a Sport)
- Reading novel
-Swimming
-Traveling
This application form must be accompanied by all the documents stated in the SCORE database.