ASIAN MEDICAL STUDENTS EXCHANGE PROGRAM (AMSEP)APPLICATION FORM

This AMSEP application form consists of some tables containing information to apply AMSEP:1. General DataThis table contains basic information that commonly needed for the application 2. Educational DataThis table contains the information of the educational background. This can make an easier placement what academic program should be provided to you as an applicant and also to get a better connection with your university (if it is needed). Status: strikethrough the one which is not suitable with you.Main medical field studied, you can write down the subject that you have passed through, for example: anatomy, biochemistry, immunology, etc.Other educational activities, you can write down your experience in conferences, summer schools, etc.3. AMSA DataThis table explores your contributions in AMSA. The notable contributions, besides your motivation below, can be considered by the host country in case there are many applicants with limited seats. Moreover, you have to include the local AMSEP officer contact in your university.4. AMSEP DataThis table is the most important part in applying AMSEP. You should describe the reason that motivated you to join AMSEP (briefly, around 150 words), especially why you want to be involved in the country you choose as your destination for AMSEP. Furthermore, you have to decide the proportion* of academic** and nonacademic*** program and also what kind of programs you would like to join.5. Additional Data (1)The first additional data can help the host country to organize the AMSEP better, such asa. the language you speak, of course you must be able to speak English, but if you write another language you can speak, maybe the host country will ask the AMSAs member there who can speak the same language with you to be one of your guides,b. hobby & skills, it will help the host country to arrange the nonacademic program,c. the food, it will help the host country very much to sort the food you can eat and you cant eat.For yes/no questions, please mention it if you answer yes.6. Additional Data (2)The second additional data is filled after the host country and you decided the exact date you are going to join AMSEP.

After completing the data, dont forget to attach the letter of recognition from your university which states that you, as one of medical students there, want to join AMSEP program in the chosen host country your university permits and supports you to join AMSEPThis letter of recognition would help the host country very much to arrange academic program.

Submit this application form to (1) AMSEP officers email in the host country and (2) loamsep@amsa-international.org; Name the file with your full name_country

* generally, AMSEP consists of 7 day program. However, the period depends on the agreement between two countries who hold the program** academic, for example: lecture, seminar, group discussion, laboratory experience, basic clinical skill, hospital observation, etc*** non academic, for example: getting along with other AMSA member, cultural workshop, sight-seeing/visit, etc. (dont forget to specify the place you want to visit in that country if you have)

G E N E R A L D A T A

Full nameDinda Olinda Dela Rosa

Nick nameDinda

Place, Date of BirthBandung, 10 September 1995

SexFemale

Address

StreetKomplek Polri, Batu Ceper.

CityTangerang

Prefecture/provinceBanten

Postal Code15122

CountryIndonesia

NationalityIndonesian

Phone number087869886695

Emaildindadelarosa@yahoo.com

MSN/YM/Skype/othersSkype : drodinda

Passport

Number

Date of expiry

E D U C A T I O N A L D A T A

University

NameChristian University of Indonesia

AddressJl. Mayjen Sutoyo No.2 Jakarta 13630

Phone number021-8094009

Emailwebmas@uki.net.id

Websitewww.uki.ac.id

Year2013

StatusMedical student

Year of graduation2018

Main medical field studiedAnatomy in general and physiology (methabolism, thermoregulation, Body Water)

Other educational activitiesEnglish First

A M S A D A T A

Member AMSA sinceDecember 2013

Position in AMSAMember

Organization experience in AMSAAMSA TIME and team bidding AMSEP

Local AMSEP officer

NameDiah Ayu Adiati

Phone number082122110093

Emaildiahayu.adiati@yahoo.com

A M S E P D A T A

Destination CountryTaiwan

What is your motivation in joining AMSEP?(Please take this seriously!)Because, AMSEP is a chance for me to get more knowledge directly by visiting the country, for example to know a disease or health status of citizen from another country especially in Taiwan for this AMSEP. Besides that, I do interest to know the culture and make a relation with some friends who have different nationality.

Have you ever joined AMSEP? No, I havent.

How many days do you want to join this exchange program?

Academic

Preclinical1

Clinical1

Non-academic4

Expectation for academic program?Hospital visit, social visit and tutorial.

Expectation for non-academic program? Sports, music or local-language class and traveling.

A D D I T I O N A L D A T A (1)

Language spoken

ActiveBahasa

PassiveEnglish

HobbySport and traveling

SkillsMusic and color guard

Religious viewMuslim

Blood typeO

Do you have a health insurance?Yes, I have.

Do you have a specific illness?No, I dont.

Are you being treated in specific medication now?No, Im not.

Do you have an allergy?No, I dont.

Are you a vegetarian?No, Im not.

Are there any food being restricted or you cant eat?Yes, there are non-halal food.

A D D I T I O N A L D A T A (2)

Arrival

Date

Time

Flight number

Airport/terminal

Departure

Date

Time

Flight number

Airport/terminal

Suggestions or comments:

Jakarta, 26 September 2013

(Dinda Olinda Dela Rosa)

AMSEP Application Form-3