AMSEP Application Form

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ASIAN MEDICAL STUDENTS’ EXCHANGE PROGRAM (AMSEP)

APPLICATION FORM
This “AMSEP application form” must be filled by the outbound delegate applying for an AMSEP. The
following is a guideline that aims to help applicants provide and process the necessary
information/documents. Please read carefully. The application form is comprised of several sections:
1. General Data
This section contains the biodata / basic information of the applicant applying for AMSEP.
2. Educational Information
This section contains the applicant’s educational background. The university details will also help the
hosting party or AMSA International contact your university if required. The information provided will help
the hosting committee decide what academic programs will be suitable for the delegates.
3. AMSA Involvement
This section explores the applicant’s contributions in AMSA. Not only will this allow the hosting
committee get a better picture of the applicant, it will also be an item considered by the host chapter in
when there is an excess of applicants for limited seats. Although motivation for applying in the AMSEP
in the next section is most important, the hosting committee will surely look at the applicant’s
contributions and activities in AMSA. Furthermore, the delegates must attach the contact of his/her local
AMSEP officer.
4. AMSEP Details
This is a crucial part of the application form. The applicant should describe the his/her purpose of
application; in other words, what motivated him/her to join AMSEP (in approximately 150 words). The
applicant should also explain why he/she chooses the destination chapter. Moreover, the applicant
should also elaborate his/her expectations of the AMSEP program later on, in terms of the proportion of
hours, and what activities to be experienced. However, applicants should keep in mind that this might
not always be fulfilled, due to restrictions in the terms of exchange and resources of the hosting
committee.
5. Miscellaneous Data
This includes additional information on the applicant, such as:
a. Language Skills: English is a basic requirement that is expected from the applicant, however if
the applicant can speak/write in other languages, this may help the hosting committee to
determine the suitable activities, or find a guide who speaks your language.
b. Hobbies & Other skills: The applicant’s hobbies and skills may help the organizing committee
arrange the nonacademic programs.
c. Health Information: This will help the committee make prior preparations for medical supplies.
This will also be essential in cases of health emergencies.
d. Food: This is vital for the hosting committee cater to your dietary needs during the exchange.
e. Religious views: Tto organize specific needs such as prayer times, meals, etc.
AMSA International AMSEP Application Form – last revised 2016 – DoA International (Gerry Tanzil)
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6. Travel Information
Travel information may be filled in / updated later, once all preparations are set and the delegates have
obtained their flight details.
Upon completion of the Application Form:
Applicants should name the Application Form with the file name: “Chapter_Full Name_AppForm”
Application forms of all delegates in a single outbound, must be compiled together and sent in bulk (in
one single email) to the hosting commitee via the National Directors.
After the delegates’ files are compiled by the National AMSEP Director, the Director should email the files to:
1. The National Director of the hosting chapter (or the organizing committee email if needed)
2. The Director of AMSEP International, at [email protected]
With the e-mail subject name: “Delegates Application Form (chapter of origin) – (destination chapter)”
Additional Note: Some chapters may require you to send university leave permit letters, please check if your
hosting chapter needs them.
APPLICATION FORM
Delegate Photo University Logo
1. GENERAL DATA
Full Name
Nick Name
Place, Date of Birth
Sex
Address
Street
City
Prefecture/Province
Postal Code
Country
Nationality
Phone Number
Email
Skype, Facebook, etc.
Passport
Number
Date of expiry
Emergency Contact Person
& Number
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2. EDUCATIONAL INFORMATION
University Details
Name of University
Address
Phone Number
Email
Website
Year of Study
Status (enrolled / on leave / etc.)
Year of Graduation
Medical Fields Studied (fields you have passed through, ex: anatomy, biochemistry, etc.)
Other Education (certified courses, summer schools, conferences, seminars, etc.)
3. AMSA INVOLVEMENT
Member of AMSA since
Position in AMSA
Organizational Experiences /
Contributions in AMSA
Local AMSEP Officer
Name
Phone number
Email
4. AMSEP DETAILS
Destination Chapter
Dates of Exchange
Motivation for joining AMSEP
(±150 words)
Have you participated in an
(if yes, please specify the dates and to which chapter)
AMSEP in the past?
EXPECTATIONS FOR AMSEP PROGRAM*
How many hours do you expect the following to be?
Academic Program … hours
Cultural Program … hours
Sightseeing Program … hours
What activities do you expect to have in the following?
Academic Program (ex: Keynote lectures, Workshops, Lab practice, Hospital visits, etc.)
Cultural Program (ex: Traditional performance, Food trail, etc.)
Sightseeing Program (ex: Visiting certain landmarks, locations, or museums, etc.)
*Note: Please note that these expectations are not guaranteed, as they depend on the terms of exchange
and capabalities of the host
5. MISCELLANEOUS DATA
Language Skills
Active
Passive
Hobbies
Skills
Religious View
Blood Type
Do you own health insurance?
Do you have specific illnesses?
Are you currently under specific
medication?
Do you have an allergy?
Are you a vegetarian?
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Do you have food restrictions?
6. TRAVEL INFORMATION (IF KNOWN)

Arrival Details
Date
Time
Flight Number
Airport / Terminal
Departure Details
Date
Time
Flight Number
Airport / Terminal
Do you own travel insurance?
7. ADDITIONAL REMARKS (if any)
Statement of Purpose:
“I hereby declare my earnest intent to participate in the corresponding AMSEP program, and that all the
aforementioned information provided in the form is accurate”
[Signature]
[Name]
[Place, Date]
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ASIAN MEDICAL STUDENTS’ EXCHANGE PROGRAM (AMSEP)

Upon completion of the Application Form:

Delegate Photo University Logo

6. TRAVEL INFORMATION (IF KNOWN)

7. ADDITIONAL REMARKS (if any)

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