Applicants Personal Details

Name
Age/Sex
Date of Birth
Nationality
Address

E-Mail ID
Phone Number
Emergency Contact #

: ________________________________________
: ________________________________________
: ________________________________________ (DD/MM/YYYY)
: ________________________________________
: ________________________________________ (Door Number)
: ________________________________________ (Street)
: ________________________________________ (City/Pin Code)
: ________________________________________ (Country)
: ________________________________________
: ________________________________________ (Inc. country code)
: ________________________________________ (Inc. country code/relation)

Applicants Passport Details

Passport Number
Issuing Authority
Issued On
Issued At
Expiry On
Require Indian Visa

: ________________________________________
: ________________________________________
: ________________________________________ (DD/MM/YYYY)
: ________________________________________ (City/State/Country)
: ________________________________________ (DD/MM/YYYY)
: ________________________________________ (Yes/No)

Applicants Education Details

Course of Study
Medical School
Country of Study
Year of Study
Joining Date
Leaving Year

: ________________________________________
: ________________________________________
: ________________________________________
: ________________________________________ (Eg: 3rd Year)
: ________________________________________ (DD/MM/YYYY)
: ________________________________________ (DD/MM/YYYY)

Applicants Clerkship Details

Intended Duration
Intended Start Date
Intended End Date
Department of Choice

Self Paying/Other

: ________________________________________ (Eg: 30 days)

: ________________________________________ (DD/MM/YYYY)
: ________________________________________ (DD/MM/YYYY)
: ________________________________________ (Option 1)
: ________________________________________ (Option 2)
: ________________________________________ (Option 3)
: ________________________________________ (If other Pls Specify)

Provided by MSAI-India:
-

Placement at University Hospital

Hands-On Clerkship (If consulting physician agrees)
Visa Assistance & Guidance
Discounted Flight Fare (via Arzoo.com)
Airport Transfer(s)
Accommodation (with A/c & Wi-Fi)
Meals (B/L/D)
Social Programs (min. 2)
Free Membership to Plexus Membership Rewards Program

Costing:
14 Days

: USD 400.00

30 Days

: USD 550.00

Acceptance Section
I, ____________________________ (name) holding ________________________ (nationality)
international passport number: ___________________________ accept that all the
information I have provided is correct and should there be any incorrect information,
MSAI-India will not be responsible. Also, I will agree to all the terms & condition that
MSAI-India & the placement university provides me once my application is accepted.
Name

Signature

FOR OFFICE USE : Filled By MSAI-India

Approval ID
Referred To
Referred Date

: MSAI/IN/2013/__/__
:
:

Date

Other:
Minimum Requirement
-

Current Medical/Dental Student

Studying in WHO listed medical school

Document(s) To Be Attached
-

Bonafide Letter from Medical School

Latest Exam Transcript
Passport Copy
National Identity Copy (if any)
Letter of Intent
Other document (if any)

Important Instruction(s)
Please compile the application form & other documents in ONE pdf file and mail it to
neo@ifmsaindia.com & msai-india@ifmsa.org
Incomplete application will be rejected without notice
Application should be submitted at least 2 months before intended date to join the
exchange program
Approval will take approximately 30 working days

FOR OFFICE USE : Filled By MSAI-India

Approval ID
Referred To
Referred Date

: MSAI/IN/2013/__/__
:
: