HAMAD MEDICAL CORPORATION

Medical Education Department

INTERNSHIP SELECTION
APPLICATION FORM

Photo

Please read FAQs before completing the Application Form in CAPITAL LETTERS

1. CANDIDATE NAME:_________________ __________________ ______________________

First Middle Family

Date of Birth:____/____/________ Place of Birth: ___________ Nationality: _______________

dd mm yyyy

Gender: □ Male □ Female Civil status: □ Single □ Married

2. For Qatar Residents

Residency permit number: _______________ Validity date: ______/_______/_____

dd mm yyyy
Name of sponsor: _______________ Sponsor’s residency permit no: _______________

Relationship: □ Father □ Mother □ Spouse □ Other_______________

Lived in Qatar: From _______________ To _______________ Born in Qatar: □ Yes □ No
3. Contacts in Qatar:
Tel. No. (Home): _______________ Mobile: _______________ Fax: _______________
Mailing address: ________________________________________ E-mail: _______________
In case of emergency, please contact: _____________________________________________
Tel. no. (Home): _______________ Mobile: _______________ Email: _______________

4. Name of medical college: ____________________________ Country:__________________

Date of graduation: ____/____/_____ OR Expected date of graduation: ____/____/_____

dd mm yyyy dd mm yyyy
Language used in medical college: □ English □ Arabic □ Others:_________________
5. QUALIFYING EXAMS RESULTS:

Exams 3-Digit Score 2-Digit Score Date No. of

Attempts
USMLE Step 1
USMLE Step 2 CK(Clinical Knowledge)

1 of 2
 HAMAD MEDICAL CORPORATION
Medical Education Department
INTERNSHIP SELECTION
APPLICATION FORM
USMLE Step 2 CS (Clinical Skills)
USMLE Step 3
IFOM-CSE

6. Language competency:

ARABIC ENGLISH OTHER LANGUAGES:

Spoken □Fluent □Fluent □Fluent
□Average □Average □Average
□Below Average □Below Average □Below Average
Written □Fluent □Fluent □Fluent
□Average □Average □Average
□Below Average □Below Average □Below Average
English Language Proficiency Test □ DONE □ NOT DONE

If done:
IELTS Score:_____________ Date:_______________
TOEFL
IBT Score:_______ Date:______ CBT Score: _______ Date: _______ PBT Score: ________ Date: _______

FOR GME OFFICE USE ONLY

7. Completed Application Form should include the following documents (COPIES):

□ Passport copy and residency permit □ USMLE Step 1 results

□ Sponsor’s passport and residency permit □ USMLE Step 2 CK results
□ 8 photos (Recently take and passport size) □ IFOM exam results
□ Medical degree (diploma) or medical □ TOEFL or IELTS results
school registration for final year

Received by: __________________________ Signature_____________ Date: ___________

Approved □

Not Approved □ Reasons:______________________________________________________

Director Medical Education: _________________________________________________________

Signature _______________________________________ Date _________________________

Application Forms can be downloaded from the HMC website- www.hamad.qa OR requested from the Medical
Education Dept. Completed applications should be delivered in person or by post. Emailed and/or faxed applications are
not accepted.

2 of 2