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/
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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