INTERNATIONAL FEDERATION OF MEDICAL STUDENTS ASSOCIATIONS

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STANDING COMMITTEE ON RESEARCH EXCHANGE APPLICATION FORM

Application issue !"#

Fa$il" na$e Fi%st na$e Nationalit" Passpo%t nu$!e% Date o' !i%t(
Me ical stu ent since) P%e*Me stu ent since
a" $ont( "ea%

E&pi%" ate Se& $ale 'e$ale

STAMP NORE SIGNATURE

Clinical stu ent since

Me ical sc(ool+ Count%" o' stu "

Stu ent,s a
St%eet Cit" Count%" P(one
count%" co e a%ea co e nu$!e% Mo!ile p(one

%ess#

Postal co e

count%" co e

a%ea co e

nu$!e%

E*$ail Languages spoken

Fa&
count%" co e a%ea co e nu$!e%

Desired country /st c(oice

nati-e lan.ua.e

ot(e% lan.ua.es

(Please try to complete all three choices)

P%o0ect na$e Depa%t$ent 1 o' 2ee3s '%o$ Cit" till

4n c(oice

P%o0ect na$e Depa%t$ent 1 o' 2ee3s '%o$ Cit" till

5% c(oice

P%o0ect na$e Depa%t$ent 1 o' 2ee3s '%o$ "es no Cit" till

I nee an in-itation lette% 6'o% -isa o% ot(e% pu%poses7

I will obtain insurance co erage !or t"e Researc" #$c"ange period% Ot"erwise &y e$c"ange will be cancelled% Applicant,s si.natu%e Date

This application form must be accompanied by all the documents stated in the SCORE database.

IFMSA SCORE CURRICULUM VITAE

Personal In ormation
Surname : Name : Date and place of birth : Address : City : Postal code : Country : Nationality : Telephone : e mail :

E!"cation
#Pre#Me!ical St"!ies :

since :

to :

I am a student at a premedical level. I provide a copy of my curriculum studi together with this CV. #Me!ical St"!ies :

Name of !ni"ersity# City# Country : $edical Student since : Clinical Student since : % ha"e completed &&& years of my &&&& year lon' course.
Main Me!ical Fiel!s St"!ie!$
studied (iochemistry (iolo'y and )enetics *istolo'y Anatomy Physiolo'y Psycholo'y+Sociolo'y $icrobiolo'y %mmunolo'y Pharmacolo'y Patholo'y Epidemiolo'y %nternal $edicine : Cardiolo'y : Endocrinolo'y : Dermatolo'y : *aematolo'y : Nephrolo'y : %nfectious Diseases : Neurolo'y : Pneumolo'y Oncolo'y )eneral Sur'ery : Orthopaedics and Traumatolo'y : Ophthalmolo'y Othorinolarin'oiatric Obstetrics and )ynaecolo'y : Paediatrics : Radiolo'y : Anaesthesiolo'y and %ntensi"e Care : ,orensic $edicine : Psychiatry : Others (if you have studied more subjects you do no find on the list above, please fill spaces below and check them) &&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&&&&&

This application form must be accompanied by all the documents stated in the SCORE database.

&&&&&&&&&&&&&&&&&&&&&

Students following an integrated medical degree programme not applying at all with the list above, can send a copy of their Curriculum Studi, together with this CV. #La%oratory or Clinical Electi&es (in nati&e co"ntry or a%roa!) :

-Name of the Institute/ ospital ! -"epartment ! -%ity ! -%ountry ! -Name of the tutor/professorto contact for further information concernin' you ! -%ontact information (tel/e-mai/address) of above (rofessor/)utor !

-#ab e$p -&ince !

-%linical e$p -to !

etc*** (reapeat the scheme above for every #aboratory or %linical +lectives you did)
#Other E!"cational Acti&ities (Lect"res' Con erences' S"mmer Schools' Me!ical Co"rses' etc()

#Lan)"a)es Spo*en

-an'ua'e : -an'ua'e : -an'ua'e : -an'ua'e :

-e"el : -e"el : -e"el : -e"el :

(asic (asic (asic (asic

Sufficient Sufficient Sufficient Sufficient

E.cellent E.cellent E.cellent E.cellent

Employment +istory$
(e,), Part Time -o%s)

Social S*ills$
(e,), Vol"ntary .or*)

Technical S*ills$
(e,), Comp"ter S*ills)

+o%%ies / Interests $
(e,), Playin) a M"sical Instr"ment' Paintin) or Playin) a Sport)

This application form must be accompanied by all the documents stated in the SCORE database.

This application form must be accompanied by all the documents stated in the SCORE database.