1、 北京大学 医学部短期进修生申请表 Short-Term Advanced Study Program Application Form PERSONAL DATA Name as it appears on your passport/ID card First name Middle name Last name Nationality _ Passport/ID card NO. _ Gender Male Female Date of Birth _ (Day /Month/Year) City of Birth _ Marital Status Unmarried Married O
2、ther Permanent address in your country/region _ _ Mailing address _ _ Telephone (including country or region codes) _ Email _ Name of the medical school you are enrolled in or graduated from _ Major and grade (number of years of clinical experience) _ The degree you will get/have got _ APPLICATION I
3、NFORMATION Proposed Program Date: _ (Please choose from below) Length: _weeks How many departments do you want to rotate in this program _? (Usually 2 weeks for one department) A. only one B. two C. more than two Department preference or lab interests 1._ 2._ Rules please provide a proof of medical/
4、accident insurance either bought in your country or in China; immunity proof is also preferred. 2. Applicants must follow the teaching plan of PUHSC. Unpermitted absence may lead to invalid internship experience. 3. A typed version of this form is preferred. Signed by: _ Application Date: _ Please Attach Your Recent Photo Here A. Frist Monday of March B. Frist Monday of April C. Frist Monday of May D. Frist Monday of June E. Frist Monday of Sep F. Third Monday of Oct G. Frist Monday of Nov H. Frist Monday of Dec
