CLINICAL /COMMUNITY ELECTIVE PROGRAMME FOR UNDER GRADUATE STUDENTS
ORGANIZED BY National Centre on Health Professions Education (NCHPE) TU INSTITUTE OF MEDICINE, 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
Medical Schools Address (in detail)
Medical student since
 Clinical student since
Expected date of graduation:
/
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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