CLINICAL / COMMUNITY ELECTIVE PROGRAMME
FOR FOREIGN MEDICAL STUDENTS

ORGANIZED BY


 National Centre for Health Professions Education (NCHPE)
TU INSTITUE OF MEDICINE (IOM), Maharajgunj, NEPAL

 

APPLICATION FORM

Family name First name
Nationality Passport number
Sex : Male     Female Date of birth     (dd-mm-yy)
  Mailing address of student    
Street Address City 
Zip Code Country
Phone Email  
   
Medical schools Address (in detail)   
Medical student since day / month / year
Clinical student since day / month / year
Expected date of graduation /
Language spoken  
Native language
Other language
Preferred department in Priority Order
 
 
 
Duration (in week)   [weeks]
within the period from (date)   [day-month-year]
to (date)   [day-month-year]
I have health insurance coverage for this period Yes   No
Desired type of clerkship Pre - clinical Clerkship
  Clinical Clerkship
  Other