FACULTY OF MEDICINE RAMATHIBODI HOSPITAL

270 Rama VI Road, Ratchathewi, , 10400

Tel: (+66) 2-201-2762-4 Fax: (+66) 2 201-2764 Email: [email protected] Website: http://med.mahidol.ac.th/international/

VISITING SCHOLAR PROGRAM APPLICATION FORM

Part 1: Personal Information

1. Last Name______

First Name ______2” x 2” Middle Name ______Recent Photo 2. Gender  Male  Female 3. Status  Single  Married  Divorced 4. Date of Birth (DD/MM/YY) ______5. Place of Birth ______6. Citizenship ______7. Address ______8. Telephone ______9. Fax ______10. E-mail Address ______. Part 2: Experience 11. Current Position ______12. Current Academic Institution Name ______13. Field(s) of Specialization ______14. Type of employer in home country  College / University  Institute  Central Government  Private Sector  Other, Please specify ______15. Address of Institution ______17. Telephone ______16. Fax ______18. E-mail ______

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FACULTY OF MEDICINE RAMATHIBODI HOSPITAL MAHIDOL UNIVERSITY

270 Rama VI Road, Ratchathewi, Bangkok, Thailand 10400

Tel: (+66) 2-201-2762-4 Fax: (+66) 2 201-2764 Email: [email protected] Website: http://med.mahidol.ac.th/international/

19. Previous work / visit to Thailand  Yes, if yes please specify  No Description of Duration Organization Specific Host Project Title Involvement (MM/YY – MM/YY) College / University

Institute

Central Government

Private Sector

Part 3: Work Plan 20. Work plan 21.1 Host Department / Division ______21.2 Write-up 200-word description from applicant on the objectives of the visit and activities / work plan and projected outcome of the visit ______21.3 Purpose  Teaching  Research  Demonstration  According to the requirement of the Faculty of Medicine Ramathibodi Hospital

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FACULTY OF MEDICINE RAMATHIBODI HOSPITAL MAHIDOL UNIVERSITY

270 Rama VI Road, Ratchathewi, Bangkok, Thailand 10400

Tel: (+66) 2-201-2762-4 Fax: (+66) 2 201-2764 Email: [email protected] Website: http://med.mahidol.ac.th/international/

21.4 From 21.3 those relate with  Patients  Medical Students  Nurse  Residents  Staff  Other, Please specific ______21.5 Topic(s) of lecture(s) / area(s) of expertise (list in priority order) ______22. Travel Information 22.1 Date of arrival ______22.2 Length of stay ______22.3 Type of visa ______23. Sponsor by  Faculty of Medicine Ramathibodi Hospital, Mahidol University  Other, Please specify______24. Supported requested  Air fare  Living allowance  Accommodations  To be arranged by Faculty of Medicine Ramathibodi Hospital  To be arranged by the applicant  Other, Please specify ______25. Please specify the potential collaborative research project between your institute and Faculty of Medicine Ramathibodi Hospital, Mahidol University. ______

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FACULTY OF MEDICINE RAMATHIBODI HOSPITAL MAHIDOL UNIVERSITY

270 Rama VI Road, Ratchathewi, Bangkok, Thailand 10400

Tel: (+66) 2-201-2762-4 Fax: (+66) 2 201-2764 Email: [email protected] Website: http://med.mahidol.ac.th/international/

I understand my responsibilities as outlined on page one of this application and would be please to be the Faculty of Medicine Ramathibodi Hospital’s Visiting Scholar. Signature ______Date of application ______

OFFICE USE ONLY

Date of Receipt ______Date Review ______Approved:  Yes  No If approved: Honoraria amount: THB ______Travel Amount: THB______Dean of Faculty of Medicine Ramathibodi Hospital’s signature: ______Date ______

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