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APPLICATION FORM FOR ELECTIVE STUDY

Surname(Title):	First name:		
     	     		
Date of birth:	     
(day/month/year)	Nationality:	     	Sex: 	
Place of birth:	     	Country of birth:	     	
Passport no:           	
Telephone no:        	E-mail:      	
Home address:      	
Address for correspondence (if not same):      	
Name, address and telephone number of next of kin:      	
Medical School (name, address, e-mail):      	
Knowledge of English (Please ‘x’): 	  Fair	  Good	  Excellent	
Year of Study:     	Expected date of Graduation:       (month/year)	
Study average last year of study:     		
Term of stay: 	FROM:  	     
(day/month/year)	TO:  	     
(day/month/year)	
Department of your interest:      	
Head of the Department:       	
Accommodation:	  Student´s Hostel „Na Kotli“
	
or   	  selected address (write address of your hotel in Hradec Králové)
     	
Attachments:  
1.	CV
2.	Passport copy
3.	Vaccination Hepatitis B recent/ within last 6 months evidence
4.	Acceptation (e-mail) by the head of the respective department
5.	Letter from your university stating your status and recommending you for the Elective study 
6.	Transcript of Records
7.	Certificate of Insurance
8.	Hygiene protocol
9.	Information for Letter of Acceptance
Notice!   Failure to take up your study here will be reported to your university	
Date :	     		
		SIGNATURE