AMERICAN INSTITUTE  OF MEDICINE

ADVANCED  MEDICAL TRAINING 

PLEASE COMPLETE THIS FORM AND ENSURE THAT YOU
HAVE SUBMITTED ALL THE REQUIRED MATERIALS


1. FAMILY NAME
FIRST NAME
2. DATE OF BIRTH
(minimum age is 18.)


 3. PLACE OF BIRTH

CITIZENSHIP
4. ADDRESS FOR CORRESPONDENCE
valid until:

Telephone No.
Fax No.

 5. PERMANENT ADDRESS (if different from response to 4)

Telephone No.
Fax No.
6. PARENTS' BACKGROUND
Father's Occupation:

Education

 7.
Mother's Occupation:

Education

8. DETAILS OF CURRENT AND PREVIOUS EDUCATION

Institutions Attended

Dates

Qualifications Obtained

9. HONOURS AND AWARDS


11. WORK EXPERIENCE

12. TRAVEL EXPERIENCE

13. FOREIGN LANGUAGE PROFICIENCY

14. REFERENCES
Please provide the names, titles, and addresses of at least two referees to whom you have given the reference forms. 
(1)

(2)

Telephone No. Telephone No.
Fax No. Fax No.

15. OTHER INFORMATION

16. SUPPORTING MATERIALS
Please ensure that the following materials are submitted along with this application form.
  1. Resumé - up-to-date, no page limit.
  2. Official Transcripts - Please submit a copy of your academic transcripts with your application in addition to requesting the official documents to be sent separately by your school or university.
  3. Two Essays, - in answer to the questions on the Essays part of this application form.
  4. Reference Letters - at least two letters of reference must be mailed and faxed by the referees directly to the Office of Admissions. (Reference form needs to be completed.)

17. I confirm that the information I have provided in this application is, to the best of my knowledge, complete and accurate.

Signature.......................................................................... Date................................

 

Please submit this application to the address below. All further inquiries regarding the admissions process should be addressed to :