Fellowship Training in Cutaneous and Laser Surgery

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Application of Short Course Training

 Fellowship Training in Cutaneous and Laser Surgery

Fellowship Training in Medical Mycology

 Fellowship Training in Contact and Occupational Dermatology

 Fellowship Training in Photobiology

 Fellowship in Basic Bioengineering of the skin for principle investigator

Course enrollment on (specific month/year) ………………………………………….

Noted : Please download this application from training.inderm.go.th ,

complete by Microsoft Word or type only.

Fill in or answer each question clearly and completely.

Attach all document required and used additional sheets if necessary.

If application are not fully complete, will not be accepted.

1.Personal Detail

Title Name  Mr.  Mrs.  Miss Gender  Male  Female

Name …….…………..…………… ……….……………………… ……………………………….

Thai Doctor ชื่อ-สกุล: ……………………………………………….…….…………………….....……………..

Personal number/ID card…………………………………Passport No.…………………………………

Type of passport  Official  Ordinary others…………………………………….……

Country of citizenship ………………………………..Medical License No. ………………………

Marital status  Single  Married  Others.………………………………………….….

Date of Birth ……../……...... …./…..……… Age………………... Nationality ………………………

Religion………………………… Dietary Restriction, if any………………………………………………

Language : Your mother tongue ………………………………………………………………………….

Proficiency ofEnglish: Excellent  Good Fair Poor

The Member of Institute of Dermatology Alumni Association No Yes

Have you previously attend any course at Institute of DermatologyNo Yes

If yes, please state the name and date of course……………………………………………………..

How do you know about this course ?  Website  Brochure

 Suggestion by………………………………..  Others .………………………………………

2.Contact Information

Home Address:.………………………………………………………………………………………………………

..…………………………………………………… Postcode/zip ……….……………..Country………………

Tel. : …………- …………- …………………… Mobile Phone ………………-…………-……………………..

Fax.: ..…….…- ………..-..………………….. Email: ……………………………………..…..……………….…

Office Address : Organization’s name...... ……………………………………………………

Address…………………………………………………………………………………………………………………………………………………………………………….Postcode/zip ………….…………. Country………………

Tel.……-…….…-…………………….Fax.….…-…..…-……………… Website……………………………..

Type of Organization  Private  Public Enterprise

 Governmental  GovernmentUniversity  Others………………..…

Correspondence address:  As Home address  As Office address

If difference:…………………………………………………………………………………………………….…

………………………………………….…… Postcode/zip …………..……………Country…………………..

Contact person in emergency :

Name: ……………………………………………………………. Relationship ………………..……………..…

Address …………………………………………………………………………………………………………………..

………………………………………………..Postcode/zip ……………..…………Country………………….. Tel. : ……….-…………-………………..…….…… Mobile :…………-.………-.………………..….………..

Fax. :………..-…………-………………………….... Email: …………………………………………………….

2. Education :In chronological order, list all degree for college/ University Graduate school.

Please attach a copy of medical school certificates and transcripts.

3. Postgraduate and Training : Please attach a copy of certificates.

4. Working Experience

Working experience (after graduated MD/MBBS)= ..………………….… Years

Present Position ……………………………...... Year of Starting………………………

Organization’s name...... ……….….………………… Department…………………………

Type of Organization……………………………………….. Website : …………….…………………

Address……………………………………………………………………………………………………………….

Postcode……………….….Country………………………Tel. ………….……….Fax. …….…..……

Responsibilities and duty :………………………………………………………………………………..

………………………………………………………………………………………………………………………

Please brief description of work, in chronological order

5. Please statement of purpose in applying for the course

...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Please read these declarations carefully. By signing this declaration you declare that you understand and agree to these terms.

I , ………………………………………………………. , of …………………………………….………

declare that :

I certify that all information in this application is true and correct. If any information and document given are false or misleading, the Institute reserves the right to refuse or reject the application.

I am medically fit and free from medical problem (Physical and mental) which may impair my ability to attend the training in Thailand.

I will be personally liable for all expenses incurred during my stay in Thailand.

If accepted for the program, I agree :

1. Follow the program and abide by the roles of the Institute of Dermatology.
2. To refrain from engaging in political activity or any from employment for profit or gain.
3. Pay the tuition fee and transaction fee by cash or by bank transfer on the specific due date in the confirmation letter and send the transfer slip with full name to confirm my payment.
4. I accept that the tuition fee are non-refundable.
5. If the tuition fee payment are not on time, the Institute have the right to select the next reserved.

I fully understand that if I am unable to attend the whole course of training, all the tuition fees, once paid, cannot be reclaimed.

I have read and consent to the Institute of Dermatology. If any of the above information and declaration are found to be untrue, my training will be terminate with immediately.

Applicant’s signature: ……………………………………………

Name……………………………………………………………

Date: …………………………………………….

Important : All section of this form must be completed. Application forms which have not been fully completed, and forms not accompanied by the documentation stipulated below, will not be considered. All enclosed copy of documents, please address “certified true copy”.

The documentation listed below must accompany this form.

1.  Application Form (type or MS word)
2.  Medical Certificate
3.  Copy of Identification Card or Passport
4.  Copy of Medical License
5.  Copy of Academic Degree & Transcript
6.  Others……………..……………………………………………………………………………….

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