APPLICATION FORM
INTERNATIONAL STUDENT EXCHANGE PROGRAM
Check List for enrollment
1) ☐A completed application form with an identification photograph attached (size 3cm X 2.4cm)
2) ☐CV
3) ☐Personal statement or letter of motivation (Maximum200 words)
4) ☐Identify two reference medical instructors
5) ☐English Proficiency Test (Type……………... Score……………)
6) ☐A current transcript
7) ☐Consent form for exchange program participation
(1/2017)
Date (Day/Month/Year): .
Name of Applicant: .
Year of Medical Student: .
APPLICATION FORMINTERNATIONAL STUDENT EXCHANGE PROGRAM
(1/2017)
PERSONAL DETAIL
Name Surname .
(ชื่อ-สกุลภาษาไทย) ชื่อเล่น .
Gender: Male Female
Student ID Number: Year: GPA: .
Date of Birth (Day/Month/Year): Age .
Address: .
.
Telephone: Mobile: .
E-mail: Fax: .
Father name: Occupation: .
Mobile: .
Mother name: Occupation: .
Mobile: .
Contact person and telephone number in case of emergency
Name: Relation: .
Telephone: E-mail: .
GENERAL DETAIL
1. Have you ever been abroad? Yes No
If yes, which country and when? Please describe
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2. English Proficiency Score for Japan and Other (Asia) Institute
Types / ScoreTOEFL / - at least 550(Paper-based Test)
- at least 213 (Computer-based Test)
- at least 79 (Internet-based Test)
IELTS / - at least 6.5
CU TEP / - at least 80
Please select your preference of universities
Continents / Countries / Institute / Scholarships / Remark Asia / Japan / Kobe University, School of Medicine
Rotation September - November / 3 / (4th - 6th year)
Juntendo University / 3 / (4th - 6th year)
Jichi Medical University
Rotation November - December / 3 / (6th year)
Tohoku University
Rotation September - October / 2 / (6th year)
Shinshu University
Rotation 1. October - November
2. February - March / 2 / (4th - 6th year)
Require basic research 1 scholarship
Osaka University
Rotation 1. September – October
2. January - March / 2 / (6th year)
Israel / Hadassah Medical Organization
Rotation September - October / 2 / (6th year)
Taiwan
Korea
Hong Kong / Name of Institute……………………………….
………………………………………………………….
…………………………………………………………. / 5 / (4th - 6th year)
……………………………………………………………… / Name of Institute……………………………….
………………………………………………………….
…………………………………………………………. / 4 / (4th - 6th year)
English Proficiency Score for Singapore, Oceania, Europe and America
Types / ScoreTOEFL / - at least 550(Paper-based Test)
- at least 213 (Computer-based Test)
- at least 79 (Internet-based Test)
IELTS / - at least 6.5
Please select your preference of universities
Continents / Countries / Institute / Scholarships / Remark Asia / Singapore / Yong Loo Lin School of Medicine, National University Singapore (Contact advance 8 months before go to elective) / 4 / (4th year)
Europe / Netherlands / University Medical Center Groningen / 2 / (4th - 6th year)
Europe
America
Oceania / ……………………………………………………………… / Name of Institute……………………………….
………………………………………………………….
…………………………………………………………. / 8 / (4th - 6th year)
3. Please state your preference of department and subspecialty.
1) .
2) .
3) .
4) .
4.Required Documents for application
4.1Curriculum Vitae
4.2 Personal statement or letter of motivation (Maximum 200 words)
4.3 Two reference medical instructors (International Relations Section will give direct evaluate form to the medical instructorsthat applicant identify)
4.3.1 Name .
Department .
4.3.2 Name .
Department .
5. Latest official transcript (GPA at least 3.0 with no ‘F’ in any subject)
6. Consent form for exchange program participation
I hereby apply for Student Exchange Program at the Faculty of Medicine Ramathibodi Hospital, Mahidol University and I confirm that the information provided above is correct as well as have read thoroughly and accepted all terms and conditions outlined.
Applicant .
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Date / / .