For academic year... Institute of Dermatology Department of Medical Services, Ministry of Public Health, Bangkok, Thailand Diploma Course in Dermatology and Dermatosurgery Please select the category of academic tuition: Private Fund JDA Scholarship (For Government official only) Photo graph Noted : Please download this application from www.inderm.go.th or www.ioddiploma.org, complete by Microsoft Word or type only. Fill in or answer each question clearly and completely. Attach all document required and used additional sheets if necessary. If application are not fully complete, will not be accepted. 1. Personal Detail Title Name Mr. Mrs. Miss Gender Male Female Name (as in the passport).... Surname First Name Middle Name Thai Doctor ช อ-สก ล :...... Personal number/id card Passport No. Type of passport Official Ordinary others. Country of citizenship..medical License No. Marital status Single Married Others..... Date of Birth../..../.. Age... Nationality Religion Dietary Restriction, if any. Language : Your mother tongue. Proficiency of English: Excellent Good Fair Poor Score of test. Special skill/distinctions. Have you previously attend any course at I nstitute of Dermatology No Yes If yes, please state the name and date of course... How do you know about this course? Website Brochure Suggestion by.. Others.
-2-2. Contact Information : Home Address:... Postcode/zip...Country Tel. : - - Mobile Phone - -.. Country code - Area code - Tel no Country code - Area code - Tel no Fax.:... -..-.... Email:..... Country code - Area code - Fax no Office Address : Organization s name... Address.Postcode/zip.. Country Tel. -. -.Fax.. -.. - Website.. Type of Organization Private Public Enterprise Governmental Government University Others.. Correspondence address : As Home address As Office address If difference :.. Postcode/zip.. Country.. Contact person in emergency : Name:. Relationship.... Address....Postcode/zip.. Country.. Tel. :.- -... Mobile : -. -...... Country code - Area code - Tel no. Country code - Area code Tel no. Fax. :..- -... Email:. Country code - Area code - Fax no 2. Education : In chronological order, list all degree for Graduated school/university. Please attach a copy of medical school certificates and transcripts. Period from to duration Degree University /Institute Location /Country GPA
-3-3. Postgraduate and Training : Please attach a copy of certificates. Period from to duration Degree Course Name /Training Program University/ Institution/Country Remark 4. Working Experience: Working experience (after graduated MD/MBBS) =... Years For Thai doctors ผ านโครงการเพ มพ นท กษะ ท รพ...ป... Present Position... Year of Starting Organization s name..... Department Type of Organization.. Website:. Address. Postcode..Country Tel...Fax.... Responsibilities and duty:.. Please brief description of work, in chronological order Date Organization Position from to name location type Responsibilities 5. Please statement of purpose in applying for the course... 6. Please describe your career goals and explain how this course will allow you to meet these goals.
-4-7. References: Please provide at least two names of professional persons and addresses who will be writing the recommendation letter on your behalf. At least one should be an accredited Dermatologist. Name Address/ Phone/ e-mail Relation Note: Attach with 2-3 letters of recommendation For more detail, may attach with your Curriculum Vitae or Resume 8. Others 8.1 Honors and distinctions... 8.2 Experience in research 8.3 Scientific Publications. Important : All section of this form must be completed. Applications which have not been fully completed, and forms not accompanied by the documentation stipulated below, will not be considered. All enclosed copy of documents, please address certified true copy. Checklist : The documentation listed below must accompany this form. Application Form (use MS word or type only) Medical Certificate Copy of Identification Card or Passport Copy of Medical License Copy of Academic Medical Degree & Transcript At least 2 of Recommendation Letters. One should from your current supervisor. Declaration sign by applicant For applicants who work for government and who apply for JDA scholarships, attach with Official Declaration or letter from the Organization in charge endorse for training.
-5- Please read these declarations carefully. By signing this declaration you declare that you understand and agree to these terms. I,., of. (Name of applicant) 9. Declaration (Country) declare that : I certify that all information in this application is true and correct. If any information and documents given are false or misleading, the Institute reserves the right to refuse or reject the application. I am medically fit and free from medical problem (Physical and mental) which may impair my ability to attend the training in Thailand. I will be personally liable for all expenses incurred during my stay in Thailand. If accepted for the program, I agree : 1. Follow the program and abide by the roles of the Institute of Dermatology. 2. To refrain from engaging in political activity or any from employment for profit or gain. 3. Pay the tuition fee THB 300,000 and transaction fee by cash or by bank transfer on the specific due date in the confirmation letter. And send the transfer slip with full name to confirm my payment. 4. If the tuition fee payment are not on time, the Institute have the right to select the next reserved. 5. I accepted that the tuition fee are non-refundable. 6. Pay the Damaged Guarantee THB 3,500 which can refund at the end of the course. 7. Companion are not allowed to participate on any academic activities, especially field trips. Institute do not certify any companion for doing visa or extend visa. 8. Pregnancy is regarded as a disqualifying condition for training. I fully understand that if I am unable to attend the whole course of training, all the tuition fees, once paid, cannot be reclaimed. I have read and consent to the Institute of Dermatology. If any of the above information and declaration are found to be untrue, my training and any scholarship will be terminate with immediately. Applicant s signature: Date:
10. Medical Certificate Note : To be completed by a registered medical practitioner after thorough clinical and laboratory examination including chest x-ray. -6-1. General information Name of candidate... Age.. Gender Male Female Weight. Height BMI.. Blood Pressure mm.hg. Pulse.. /min Allergic to any medication or food? No Yes;.... Have any significant or serious illness? No Yes;.. Chest X-Ray report. 2. Is the person examined at present in good health and enjoying full work capacity?.... 3. Is the person examined able physically and mentally to undergo training? 4. Is the person examined free from infectious disease (for example T.B., Trachoma, AIDS ) which could present risks for both the candidate and his/her contacts during the training?.,.. 5. Does the person examined have any condition or defect which might require treatment during his/her training?......... Full name and address of Examining Physician with official stamp and signed Name.. signature.. Hospital Address Date. e-mail.. Medical License no...
-7-11. Official Declaration To be complete by the Applicant s Government On behalf of (Name of Organization) Government of.,country. Address I, Position. (Name of the Organization in Charge) have examine the documents in this form and found them true. I certified that. (Name of the applicant) ID Card/Passport no.., has attained a level of proficiency in both Clinical Professional and English Communication to enable him to follow the course of training. Accordingly, I agree to endorse. (Name of the applicant) to train the Diploma course in Dermatology and Dermatosurgery. to nominate for JDA scholarship Official stamp Signature Name... (Name of the organization in charge) E-mail.. Phone.. Date.