INMED - Institute for International Medicine

Institute for International Medicine
Equipping healthcare professionals to serve the forgotten

INMED International Public Health Certificate Application

Instructions

Please allow at least 60 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 $50 non-refundable 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 4

Date of application: 7/29/2010

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:
T-shirt Size:
Academic Degree:
Specialty/Title:
Occupation:
How Did You First Hear Of INMED?:
Please Describe How You Heard:
Marital status:
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 that will be completed prior to International Elective (if applicable):
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:

Emergency Contact Information

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

Elective Schedule

Electives are offered year round, and generally must be at least 4 weeks duration. Please list in order of preference 1-3 the dates you are available for this elective:

1. Departing Date Returning Date

2. Departing Date Returning Date

3. Departing Date Returning Date

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