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BMEP - Biomedical Education Program
Intern
Questionary Display
Questionary Overview
Scholarship information
BMEP history
Who can apply
How to apply
Alumni
Team/ Contact
imprint/ legal notice
How to apply
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Application Form
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Application Form
Academic Year
/
15th of April 2021
Applicant Name
(family name in capital)
(first names)
Present mailing address (for correspondence)
(street address)
(postal code, city)
(phone number)
(e-mail)
Private Issues
(Birth date and place)
Marital status
married
single
widowed
separated
common law marriage
(Citizenship)
Name and address of relatives who should be informed in case of emergency
Backing Account
Account holder
Bank institut
Bank account number
BLZ
IBAN
BIC
Curriculum vitae
Gymnasium/High School
Further approved funding (Rotary, private funds etc.)
Home university
University adress
Student of (discipline, e.g., medicine)
Years completed
First (medical) major (e.g. Physikum)
(date and results)
State examination (date and results)
(if not yet taken, please indicate expected date)
Other examinations
Scientific Activities
Have you started your Doctoral Thesis?
yes
no
If YES, Subject of Doctoral Thesis work
Thesis Supervisor/Mentor:
(Name)
(Email)
Name of Home Mentor (if not Thesis Supervisor):
Mentor in Host Institution:
(Name)
(Email)
Are you interested in Clinical Rotations during your stay at your Host Institution?
yes
no
If YES, can the clinical rotations be organized through your Host Mentor?
yes
no
If NO, why not
Additional Information regarding Host, Host Institution and/or Host City
Estimated Costs of Exchange (required by US immigration):
Travel
Housing
Health insurance
Available support from personal funds
Additional Information
Extracurricular activities, interests and hobbies
Does your medical school require a report on your elective studies?
yes
no
Additional documents:
(letter of reference, school report, etc.)
Attach file
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