Clinical Experience Course Application Form
Faculty of Medicine, Burapha University
Personal Information
Surname *
Given Name *
Middle Initial
Country of Citizenship *
Gender *
Male
Female
Date of Birth *
Place of Birth
Passport No *
Passport Valid Until *
Tel & Cell phone *
Please enter a valid phone number.
E-mail *
Please enter a valid email address.
Religion
Marital Status
Upload 1-inch Photo *
Program Information
Type of Program *
Short-Term Clinical Elective Clerkship
Observership
Other
Please specify *
Please select program type.
Major of Applying (Select up to 3) *
Department of Pediatrics
Department of Ophthalmology
Department of Psychiatry
Department of Pathology
Department of Forensic Medicine
Department of Radiology and Nuclear Medicine
Department of Anesthesiology
Department of Preventive and Family Medicine
Department of Rehabilitation Medicine
Department of Surgery
Department of Otolaryngology (ENT)
Department of Obstetrics and Gynecology
Department of Orthopedics
Department of Internal Medicine
Department of Emergency Medicine
Please select at least 1 and not more than 3 majors.
Medical Student Year *
-- Select Year --
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Period of Time *
Start Date *
End Date *
Please select period of time.
Educational Background *
Expectation of the Course *
Required Supporting Documents
1. MedBUU Application Form (PDF) *
Download
2. HCW Immunization Form (PDF) *
Download
3. Dean Reference Letter (PDF) *
4. Medical Elective Support Letter (PDF) *
5. Transcript of Record (PDF) *
6. Student ID (PDF/JPG/PNG) *
7. Valid Passport (PDF/JPG) *
8. MDU Insurance (PDF)
9. Picture for Name Badge (JPG/PNG) *
10. English Level Certificate (if applicable) (PDF)
Maximum file size: 5MB per file
Message to the Committee for Consideration (if applicable)
This section is optional. You may leave it blank if not applicable.
Submit Application