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APPLICATION FOR EXCHANGE. Passport number____. Nationality__. Telephone: ___ Fax: __. Email (in CAPITALS):____. MedicalAPPLICATION FOR EXCHANGE
_______________________________________________________________
Telephone: ___________________________________ Fax: __________________
Email (in CAPITALS): ____________________________________________________
Medical School & City
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Year of study: ______ Languages spoken: ___________________________
Department
Dates for exchange(Arrival/Departure):
______d/______m/______y to______d/______m/______y
or: _________weeks, in_________________(month)__________________(year)I would prefer to do clinical work/observe†in the department of: _____
_______________________________________________________________
Remarks (invitation paper requirements/other): _______________________________________________________________
_______________________________________________________________
______________________
Applicant’s signature
________________________________
Local Exchange Officer’s signature Date: _____d/_____m/_____y
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