PRINCE OF SONGKLA UNIVERSITY

FACULTY OF MEDICINE
Office of International Affairs
15 Karnjanavanit Road, Hat Yai, Songkhla 90110, Thailand
Tel. 66 7445-1169, Fax: 66 7421-2900
Email:inter@medicine.psu.ac.th

Application for Elective program

Photo

Personal Profile

First name: Middle name: Surname:

Title or Year of study:
Date of Birth: Marital Status: Age: Gender:
Name of Medical school and address:
Country of origin: Nationality:
Mailing address:
Passport Number: Tel No:
Email address:
Urgent contact No:

Objectives: Please fill in this information (1-4) and then write a short essay based on your
answers describing the following items (no more than 500 words) in English (5).

1) Purpose of visit:
2) Elective courses or observation topic(s) requested:
Example: Course Name: Infectious Disease Department: Internal Medicine week(s): 2

Course Name: Department: week(s):

Course Name: Department: week(s):
Alternative course(s) if the above subject(s) are not available:
Course Name: Department: week(s):
Course Name: Department: week(s):
3) Total number of week(s):
4) Starting: Ending:
5) Your personal statement describing your interests to study from participating in
this program (please type only)

Pri nc e o f So n gk l a U n i v ers i t y
 PRINCE OF SONGKLA UNIVERSITY
FACULTY OF MEDICINE
Office of International Affairs
15 Karnjanavanit Road, Hat Yai, Songkhla 90110, Thailand
Tel. 66 7445-1169, Fax: 66 7421-2900
Email:inter@medicine.psu.ac.th

Please attach the following documents with this application.

1. A completed application form along with your recent photograph
2. A recommendation letter from your supervisor/ Dean / Clinical Director
3. CV or resume
4. A copy of your passport
5. An evaluation form required by your home university (if needed)
6. Please recheck with your school requirement if your school needs any special
document from our school to complete your clinical elective/clerkship/traineeship
such as contract or agreement of affiliation etc.
**Remark:** All above-mentioned documents should be submitted to the Office of
International Affairs, Faculty of Medicine, Prince of Songkla University two months prior
to your elective course.

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Please continue to the accommodation requested from below

Pri nc e o f So n gk l a U n i v ers i t y
 PRINCE OF SONGKLA UNIVERSITY
FACULTY OF MEDICINE
Office of International Affairs
15 Karnjanavanit Road, Hat Yai, Songkhla 90110, Thailand
Tel. 66 7445-1169, Fax: 66 7421-2900
Email:inter@medicine.psu.ac.th

Accommodation Requested Form

Name: Surname:

Preferred type of accommodation: Please put ✓ in front of your preferred type.

Faculty of Medicine’s accommodation

( ) Room with fan costs USD 4 per day per person

( ) Room with air-conditioned costs USD 10 per day per person

** It takes around 5-10 minutes walk since they are behind the hospital buildings.
PSU guest house
( ) Single bedroom
 For two people
 550 Baht per night or ~ USD 16
( ) Suite room
 For two people
 650 Baht per night ~ USD 18
( ) Big bedroom
 For 4 people
 800 Baht per night ~ USD 22
** All rooms with air-conditioned**
It takes around 10-15 minutes walk, located near PSU Lake and bordering a mountain range.

Check in date: (dd/mm/yy) Check out date :(dd/mm/yy)

Total number of night(s):

** Please kindly note that the room cannot be guaranteed and depends on number of
students and availability of the requested duration. However, we, Office of International
Affairs, will assist you our best to settle you in the appropriate accommodation if our on-
campus housing is not available. The students are also expected to pay the whole money
within the first week of arrival

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Pri nc e o f So n gk l a U n i v ers i t y