Application Form


Academic Year /
3rd of October 2022



Mandatory fields are marked with '*'

Applicant Name


* Family name (in capital)
* First name
* Birth date
 
* Birthplace


Optionally, you can upload a photo. Image:
Contact Information


* Streetname
* House number
* Postal code
* City
* Phone number
* E-Mail
Private Issues

Citizenship


Contact Information of emergency contact

Family name
First name
Streetname
House number
Postal code
City
Phone number

Banking Account

* Account holder
* Bank institut
* IBAN
* BIC

Scientific Activities

* Currently supported by a DAAD-Funding?

* Currently enrolled in a full-time degree program?

* Home university name


Home university adress

* Street name of university
* House number
* Postal code
* City

* Descipline


Student data

* Have you already written your doctoral thesis?

If YES: Title of the doctoral thesis
If YES: Family name of Mentor of doctor thesis
If YES: First name of mentor of doctor thesis
BMEP specific information

Local mentor ? Mentor at German university.

* Family name of local mentor
* First name of local mentor


University

* University name
* Streetname
* House number
* Postal code
* City
* Country
* E-Mail



Host mentor ? Mentor at the host institution abroad.

* Family name of host mentor
* First name of host mentor


University

* University name
* Streetname
* House number
* Postal code
* City
* Country
* E-Mail


* Project title

* Are you interested in clinical rotations during your stay at your Host Institution (medical students only)?
 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
Additional Information

Extracurricular activities, interests and hobbies

Does your medical school require a report on your elective studies?
 yes   no


Additional documents:


We need the following files from you in pdf format:
  1. Cover Letter
  2. CV (curriculum vitae)
  3. Research Proposal
  4. Local Mentor Letter
  5. Host Mentor Letter
  6. OPTIONAL: Other (references, certificates, ...)
Please upload maximum 5 to 6 documents. Collective documents in defined order prefered.
NO MORE!
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