ASIAN MEDICAL STUDENTS EXCHANGE PROGRAM (AMSEP)

APPLICATION FORM

This AMSEP application form consists of some tables containing information to apply AMSEP:
1. General Data
This table contains basic information that commonly needed for the application
2. Educational Data
This table contains the information of the educational background. This can make an easier
placement what academic program should be provided to you as an applicant and also to
get a better connection with your university (if it is needed).
Status: strikethrough the one which is not suitable with you.
Main medical field studied, you can write down the subject that you have passed through,
for example: anatomy, biochemistry, immunology, etc.
Other educational activities, you can write down your experience in conferences, summer
schools, etc.
3. AMSA Data
This table explores your contributions in AMSA. The notable contributions, besides your
motivation below, can be considered by the host country in case there are many applicants
with limited seats. Moreover, you have to include the local AMSEP officer contact in your
university.
4. AMSEP Data
This table is the most important part in applying AMSEP. You should describe the reason
that motivated you to join AMSEP (briefly, around 150 words), especially why you want to
be involved in the country you choose as your destination for AMSEP. Furthermore, you
have to decide the proportion* of academic** and nonacademic*** program and also what
kind of programs you would like to join.
5. Additional Data (1)
The first additional data can help the host country to organize the AMSEP better, such as
a. the language you speak, of course you must be able to speak English, but if you write
another language you can speak, maybe the host country will ask the AMSAs member
there who can speak the same language with you to be one of your guides,
b. hobby & skills, it will help the host country to arrange the nonacademic program,
c. the food, it will help the host country very much to sort the food you can eat and you
cant eat.
For yes/no questions, please mention it if you answer yes.
6. Additional Data (2)
The second additional data is filled after the host country and you decided the exact date
you are going to join AMSEP.
After completing the data, dont forget to attach the letter of recognition from your
university which states that
- you, as one of medical students there, want to join AMSEP program in the chosen host
country
- your university permits and supports you to join AMSEP
This letter of recognition would help the host country very much to arrange academic program.
Submit this application form to (1) AMSEP officers email in the host country and (2)
loamsep@amsa-international.org; Name the file with your full name_country
* generally, AMSEP consists of 7 day program. However, the period depends on the agreement between two countries
who hold the program
** academic, for example: lecture, seminar, group discussion, laboratory experience, basic clinical skill, hospital
observation, etc

AMSEP Application Form-1

*** non academic, for example: getting along with other AMSA member, cultural workshop, sight-seeing/visit, etc.
(dont forget to specify the place you want to visit in that country if you have)

AMSEP Application Form-2

Full name
Nick name
Place, Date of Birth
Sex
Address

Street
City
Prefecture/province
Postal Code
Country

Nationality
Phone number
Email
MSN/YM/Skype/other
s
Passport

GENERAL
DATA
Dinda Olinda Dela Rosa
Dinda
Bandung, 10 September 1995
Female
Komplek Polri, Batu Ceper.
Tangerang
Banten
15122
Indonesia

Indonesian
087869886695
dindadelarosa@yahoo.com
Skype : drodinda

Number
Date of expiry

EDUCATIONAL
University

Name
Address
Phone number
Email
Website

Year
Status
Year of graduation
Main medical field
studied
Other educational
activities

Member AMSA since

Position in AMSA
Organization
experience in AMSA
Local AMSEP officer
Name
Phone number
Email

Destination Country
What is your
motivation in joining
AMSEP?
(Please take this
seriously!)
Have you ever joined
AMSEP?

DATA

Christian University of Indonesia

Jl. Mayjen Sutoyo No.2 Jakarta 13630
021-8094009
webmas@uki.net.id
www.uki.ac.id
2013

Medical student
2018
Anatomy in general and physiology (methabolism,
thermoregulation, Body Water)
English First

AMSA
DATA
December 2013
Member
AMSA TIME and team bidding AMSEP
Diah Ayu Adiati
082122110093

diahayu.adiati@yahoo.com

AMSEP
DATA
Taiwan
Because, AMSEP is a chance for me to get more knowledge directly by
visiting the country, for example to know a disease or health status of
citizen from another country especially in Taiwan for this AMSEP.
Besides that, I do interest to know the culture and make a relation
with some friends who have different nationality.
No, I havent.

How many days do you want to join this exchange program?

Academic
Preclinical
1
Clinical
1
Non-academic
4
Expectation for
Hospital visit, social visit and tutorial.

AMSEP Application Form-3

academic program?
Expectation for nonacademic program?

Sports, music or local-language class and traveling.

ADDITIONAL
Language spoken
Active
Passive
Hobby
Skills

Religious view
Blood type
Do you have a health
insurance?
Do you have a specific illness?
Are you being treated in
specific medication now?
Do you have an allergy?
Are you a vegetarian?
Are there any food being
restricted or you cant eat?

D A T A (1)

Bahasa
English
Sport and traveling
Music and color guard
Muslim
O
Yes, I have.
No, I dont.
No, Im not.
No, I dont.

No, Im not.
Yes, there are non-halal food.

ADDITIONAL

D A T A (2)

Arrival
Date
Time
Flight number
Airport/terminal
Departure
Date
Time
Flight number
Airport/terminal

Suggestions or comments:

Jakarta, 26 September 2013

(Dinda Olinda Dela Rosa)

AMSEP Application Form-4

AMSEP Application Form-5