INMED - Institute for International Medicine

Institute for International Medicine
Equipping healthcare professionals to serve the forgotten

INMED International Medicine Diploma Application

Instructions

Healthcare professionals and healthcare profession students who meet all qualifications described on the INMED International Medicine Diploma details page are invited to submit an application. The application should be submitted only after completion of all these requirements. Please contact INMED with any questions in this regard.

Please allow at least 90 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 $95 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 3

Date of application: 9/2/2010

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:
Birth date:
Sex:
Country of Citizenship:

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

Year of Training:
Core Rotations & Electives completed to date:
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:

Alternative Contact Information

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

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