Faculty of Medicine, Prince of Songkla University

Faculty of Medicine, Prince of Songkla University

PRINCE OF SONGKLAUNIVERSITY

FACULTY OF MEDICINE

Office of International Affairs

15 Karnjanavanit Road, Hat Yai, Songkhla90110, Thailand

Tel. 66 7445-1169, Fax: 66 7421-2900

Email:

Application for Elective program

Personal Profile

Name:Titleor Year of study:

Date of Birth:Marital Status: Age: Gender:

Nameof Medical school and address:

Country of origin: Nationality:

Mailing address:

Passport Number:Tel No:

Email address:

Urgent contact No:

Objectives:Please fill in this information (1-4) and then write a short essay based on your answersdescribing the following items (no more than 500 words) in English(5).

1) Purpose of visit:

2) Elective courses or observation topic(s) requested:

Example: Course Name:Infectious Disease Department: Internal Medicine week(s): 2

Course Name: Department: week(s):

Course Name: Department: week(s):

Alternative course(s) if the above subject(s) are not available:

Course Name:Department: week(s):

Course Name:Department: week(s):

3) Total number of week(s):

4) Starting: Ending:

5) Your personal statement describing your interests to study from participating in this program (please type only)

Please attach the following documents with this application.

  1. A completed application form along with your recent photograph
  2. A recommendation letter from your supervisor/ Dean / Clinical Director
  3. CV or resume
  4. A copy of your passport
  5. An evaluation form required by your home university (if needed)
  6. Please recheck with your school requirement if your school needs any special document from our school to complete your clinical elective/clerkship/traineeship such as contract or agreement of affiliation etc.

**Remark:** All above-mentioned documents should be submitted to the Office of International Affairs, Faculty of Medicine, Prince of Songkla University two months prior to your elective course.

*******************************

Please continue to the accommodation requested from below

↓

Accommodation Requested Form

Name: Surname:

Preferred type of accommodation: Please put ✓in front of your preferred type.

  • Faculty of Medicine’s accommodation

( ) Room with fan costs USD 4 per day per person

( ) Room with air-conditioned costs USD10 per day per person

** It takes around 5-10 minutes walk since they are behind the hospital buildings.

  • PSU guest house

( ) Single bedroom

  • For two people
  • 550 Baht per night or ~ USD 16

( ) Suite room

  • For two people
  • 650 Baht per night ~USD 18

( ) Big bedroom

  • For 4 people
  • 800 Baht per night ~ USD 22

** All rooms with air-conditioned**

It takes around 10-15 minutes walk, located near PSULake and bordering a mountain range.

Check in date: (dd/mm/yy) Check out date :(dd/mm/yy)

Total number of night(s):

** Please kindly note that the room cannot be guaranteed and depends on number of students and availability of the requested duration. However, we, Office of International Affairs, will assist you our best to settle you in the appropriate accommodation if our on-campus housing is not available. The students are also expected to pay the whole money within the first week of arrival

*********************

Top View