CLINICAL CLERKSHIP OBSERVATION FOR POST GRADUATES
Organized by National Centre For Hearth Professional Education (NCHPE) TU INSTITUE OF MEDICINE (IOM), Maharajgunj, Nepal
Application Form
 
Family Name

First Name
Nationality
 Passport Number
Gender: Male Female Date of Birth
Mailing Address of Student
Street Address
City
Zip Code
 Country
Work Address (in detail)

Practicing since
 Speciality
Practicing License no.: (Registration no. in the country of residence)
/
Language Spoken
  
Native Language
 Other Language
Preferred speciality in the department in priority order

Duration (in week)
[weeks]
within the period from (date)
 to (date)
I have health insurance coverage for this period Yes No
Desire type of Clerkship

Pre-clinical Clerkship

Clinical Clerkship

Others
 
 
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