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Joint Master of Health Professions Education (JMHPE)
Program 2014 – 2015 /
Suez CanalUniversity
Faculty of Medicine
Medical Education Department

JOINT MASTER OF HEALTH PROFESSIONS EDUCATION(JMHPE)

Developed in collaboration between Maastricht University (the Netherlands) and

Suez CanalUniversity (Egypt)

APPLICATION FORM

2014 – 2015

Please return this form (please fill in electronically and not handwriting) together with the required supporting documents (as clear scanned copies)to:

Medical Education Department

Faculty of Medicine

Suez CanalUniversity

And

Universiteit Maastricht

Department of Educational Development of Research

Joint Master of Health Professions Education Programme

Maastricht University, School of Health Professions Education, Joint Master of Health Professions Education Programme

P.O. Box 616, NL - 6200 MD MAASTRICHT, The Netherlands

Tel.: +31 43 388 5777/8 / Fax. +31 43 388 5639

E-mail: Website:SHE.Maastrichtuniversity

Suez Canal University, Faculty of Medicine,Medical Education DepartmentRound Road, Ismailia 41111, Egypt

Tel.: +2 064 3229 129 /Fax: +2 064 3227 426

E-mail: and ebsite:

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Joint Master of Health Professions Education (JMHPE)
Program 2014 – 2015 /
Suez CanalUniversity
Faculty of Medicine
Medical Education Department
  1. Personal data

Name of Applicant(full name is required):------

Date: ------

Family Name/surname------

First Name(s)------

Title (Prof/Dr/Mr/Ms/Miss/Mrs)------

Accurate Mailing Address(Please note that we will send the JMHPE educational materials to this address, so please be sure it is accurate and detailed):

------

------

------

Telephone NumberHome ------

Telephone number Mobile:------

Telephone Number Work------Fax No:------

Email Address (it's better to use Gmail):------

Home Address:------

------

------

Date of Birth (dd/mm/yy)------

Country of Birth:------

Nationality:------

Sex:FemaleMale

Name and address of your ------

Next Relative:------

------

Relationship:------

B. Language (for non-native speakers only)

Level of English proficiency to be: Excellent Good FairPoor

C. University Education (Start with highest grade obtained, if necessary use additional sheets)

Degree Obtained:------

Name of University:------

Address of University:------

------

Studied from (dd/mm/yy):------Until (dd/mm/yy):------

Degree Obtained:------

Name of University:------

Address of University:------

------

Studied from (dd/mm/yy):------Until (dd/mm/yy):------

D. Work Experience (Start with current positions, if necessary use additional sheets)

Present Post:------

Job Title:------

Address of Employer:------

------

Telephone Number at Work:------Fax No: ------

Describe responsibilities and tasks:------

------

------

------

Length Employment (dd/mm/yy):------Until (dd/mm/yy)------

E. Financial Support:

How do you plan to finance By myself (only approved if guaranteed by a financial

your education?statement)

Through my institute/employer (financial statement required)

I have obtained a fellowship from:

------

F. Computer Experience

Are you familiar with the use of?

Word:Yes No

E-mail:Yes No

Internet:Yes No

G. Education in Statistics

Did you have any education in statistics? Yes No

H. Name verification:

Write your name as you want it to appear on the certificate.

------

I. Enclosures

A coloured scanned copy of your passport (identification page);

Arecentcolouredpassport-size photograph;

Certified photocopies of Higher Education Diplomas;

Certified copies need to be signed by a formal person from the institute you received the Higher Education diploma from. It should be bearing a seal or stamp from the head or registrar and a signature with the name and title of this person).

If you cannot arrange the above then you should certify the diploma by an official person like a notary, someone from the embassy or town hall. Again the diploma needs to have a seal or stamp with a signature and name of this person.

Maastricht University, School of Health Professions Education, Joint Master of Health Professions Education Programme

P.O. Box 616, NL - 6200 MD MAASTRICHT, The Netherlands

Tel.: +31 43 388 5777/8 / Fax. +31 43 388 5639

E-mail: Website:SHE.Maastrichtuniversity

Suez Canal University, Faculty of Medicine,Medical Education DepartmentRound Road, Ismailia 41111, Egypt

Tel.: +2 064 3229 129 /Fax: +2 064 3227 426

E-mail: and ebsite: