Application Form


Academic Year /

13th of December 2018



Applicant Name

(family name in capital)
(first names)


Image:
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?
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.)
x
If you are a human, leave this field empty

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