APPLICATION FOR EXCHANGE. Passport number__. Nationality. Telephone: _ Fax: . Email (in CAPITALS):____. Medical

APPLICATION FOR EXCHANGE

Name: ___________________________________________________		PHOTO
Date Of Birth: _____d/_____m/_____y Passport number____________________ Nationality__________________________	Sex: M/F

Address(during term-time):

_______________________________________________________________

Telephone: ___________________________________ Fax: __________________

Email (in CAPITALS): ____________________________________________________

Medical School & City

_______________________________________________________________

Year of study: ______ Languages spoken: ___________________________

1st choice

2nd choice

3rd choice

Department

please note that we will give you one of your 3 wish departments, not necessary 1st choice

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

APPLICATION FOR EXCHANGE. Passport number____. Nationality__. Telephone: ___ Fax: __. Email (in CAPITALS):____. Medical