INMED - Institute for International Medicine

Institute for International Medicine
Equipping healthcare professionals to serve the forgotten

INMED International Medicine Certificate Application

Instructions

Please allow at least 60 minutes to complete this application process. Currently, it is not possible to save your unfinished application and then later return. Be prepared to submit a personal photo and a $50 non-refundable application fee, payable via credit or debit card, or by personal check.

Please complete all fields. Some questions call for descriptive answers. It is to your advantage to provide as full a response as possible.

We highly recommend you save a personal copy of your application in case it is not received by INMED. You may save each completed page as a web page, print a hard copy of each completed page, and/or save your responses in a Word document.

Step 1 of 4

Date of application: 7/29/2010

General Information

First name:
Last name:
Age:
E-mail Address:
Alternate E-mail Address:
Home phone:
Mobile phone:
Home Mailing Address Line 1:
Home Mailing Address Line 2:
City:
State
Zip Code:
Country:
Academic Degree:
Specialty/Title:
Occupation:
How Did You First Hear Of INMED?:
Please Describe How You Heard:
Marital status:
Birth date:
Sex:
Country of Citizenship:
T-shirt Size:

Academic Institution Complete this section if you are currently enrolled as a student, resident or fellow.

Year of Training:
Core Rotations & Electives that will be completed prior to International Elective (if applicable):
Academic Institution name:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip Code:
School/Residency phone:
Academic Coordinator's First Name:
Academic Coordinator's Last Name:
Coordinator's e-mail:
Coordinator's phone:

Emergency Contact Information

Emergency Contact's First Name:
Emergency Contact's Last Name:
Relationship:
E-mail Address:
Home phone:
Mobile phone:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip Code:

Elective Schedule

Electives are offered year round, and generally must be at least 4 weeks duration. Please list in order of preference 1-3 the dates you are available for this elective:

1. Departing Date Returning Date

2. Departing Date Returning Date

3. Departing Date Returning Date

Optional International HIV Medicine Certificate Enrollment

Students enrolled in the INMED International Medicine Certificate program may also have an opportunity to complete the INMED International HIV Medicine Certificate. Both Certificate programs can be conducted simultaneously when the student selects an International Medicine Training Site that is also listed as an International HIV Medicine Training Site.

Would you like to make simultaneous application for the International HIV Medicine Certificate?

If yes, please explain your motivation for studying international HIV medicine:

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