International Medical University (IMU)

Student Mobility Programme (SMP) Outgoing students

This form should be used by all outgoing students from IMU and submitted to the IMU Academic
Services (Student Records and Placements). All forms to submitted at least 2 months before
commencement of activity
All applicants are required to complete Parts A, B and C.
Please provide current curriculum vitae with your application.
Any necessary supporting documents must be attached.
Students who need financial assistance are required to complete Part D.
Applicants should refer to the IMU SMP Guidelines before submitting an application.

PART A: Students Particulars

Name of Student: ________________________________________________
Surname: _______________________________________
First Name: _____________________________________
Date of Birth: _______________________________
Age: ___________
House Telephone No / Mobile No.: _______________________________
E-Mail Address: _______________________________________
Sex: Female

Male

Nationality: ________________________________
Student ID No: _______________________________
Name of Programme: ______________________________
Semester: ______________________________
Type of Activity/Programme:

Internship
Research
Elective Module
Study Visit
Exchange Programme
Others (Please state):__________________________________

Title of Activity/Programme: ___________________________________________________

1

Duration of the activity: ________________________________________________________

Date of Commencement: ____________________

End Date: ______________________

Name of mentor in IMU: ___________________________________________________________

Name of programme coordinator in IMU: _____________________________________________

Details of partner organisation or institution

Name(s) of
organisation/institution:
Name of contact person at
the organization /
institution:
Designation of contact
person at the organization
/ institution:
Address:

Phone:

Country code:

City Code:

Phone Number:

Fax:

Country code:

City Code:

Phone Number:

E-mail:
Organisation/institution
web address:

Part B: Learning Objectives and Outcomes

Please state your learning objectives. Outline the activities that you propose to undertake.

Please state your learning outcomes. At the end of your visit, what will you expect to have
achieved?

PART C: Partner Organisation/Institution and Logistics

Please provide further details of the partner organisation/institution outlining the benefits of
your attendance.

Briefly outline your logistics including accommodation, travel plans and ground transport
arrangements.

I agree, consent and declare that:

(a)

all information provided to IMU in connection with this document and elsewhere (including
any and all continuing and new information given to IMU) are true, accurate and complete to
the best of my knowledge and belief;

(b)

it is my responsibility to inform IMU of any modifications, additions or deletions to the said

information, as necessary;

(c)

all information provided by me to IMU may be used by IMU for its own management
purposes, eg: to identify, collate or aggregate information or to perform statistical analysis;
and

(d)

such information may be occasionally shared with other organizations in line with legal
compliance including disclosure obligations with relevant connected business partners and
regulators.

I confirm that I undertake this activity/programme on my own volition and agreement. I have fully
satisfied myself as to the usefulness of this activity / programme and have made all due inquiries
into all risks, safety, medical, transport, accommodation and other logistical issues for which I have
adequately made arrangements and provisions for.
I confirm and agree to hold IMU, its officers and staff, including its holding and associated
company(ies) and their officers and staff harmless and not liable and shall further, fully indemnify all
such parties against all and any claims, losses, costs, expenses, including reasonable solicitors fees
and charges in the event of any loss, cost, expense, personal injury or death suffered by me in my
participation in this activity/programme including for any inaccuracy in the information provided by
me in this document or elsewhere.
Signature: ____________________________________
Name of Applicant: ___________________________

Approved By Lecturer in-charge/Programme Coordinator / Head of Programme:

Signature: ____________________________________

Name: _______________________________________

Part D: Financial Proposal

(Complete this only if you need financial aid from IMU)
This part should only be completed if financial assistance from IMU is requested.
Applicants should refer to the IMU SMP Guidelines for the eligibility criteria.
Students who rely solely on financial assistance are advised not to make any commitments with
the partner organisation/ institution, pending the approval of their application.
Indicate the amount requested for each activity with justification.
Activity Item

Justification

Amount (RM)

1.0 Travel and Subsistence Costs

1.1 Travel
1.2 Accommodation
1.3 Subsistence (please itemise)
Sub-Total (travel and subsistence)
2.0 Other Costs (please itemise)
2.1
2.2
2.3
2.4
Sub-Total (other costs)
Total
Itemize any secured external funding which you have obtained:
Activity Item

Justification/Funding body

Amount (RM)

3.0 Travel and Subsistence Costs

3.1 Travel
3.2 Accommodation
3.3 Subsistence (please itemise)
Sub-Total (Travel and subsistence)
4.0 Other Costs (please itemise)
4.1
4.2
4.3
4.4
Sub-Total (Others)
Total

Approved Amount: RM________________________

Justification: ____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Tabled to the SMP Meeting on: __________________

Signature of Chairperson of the Meeting:

____________________________________________
Name:
______________________________________________

Form B

The International Medical University (IMU)

IMU Student Mobility Programme Outgoing Students
Students Attributes
Name of student: ___________________________________
Name of programme: _______________________________________________________
Name of University: ________________________________________________________
Academic ability

Excellent

Good

Satisfactory

Poor

Leadership

Excellent

Good

Satisfactory

Poor

Self- motivation

Excellent

Good

Satisfactory

Poor

Interpersonal skills

Excellent

Good

Satisfactory

Poor

Maturity

Excellent

Good

Satisfactory

Poor

Responsibility

Excellent

Good

Satisfactory

Poor

Clinical skills

Excellent

Good

Satisfactory

Poor

Class participation

Excellent

Good

Satisfactory

Poor

English proficiency

Excellent

Good

Satisfactory

Poor

(if applicable)

Additional comments: ____________________________________________________________

_______________________________________________________________________________
Signature of Mentor:
__________________________________

Name:_____________________________

Date :_____________________