APPLICATION FORM FOR AN ELECTIVE APPOINTMENT

Faculty of Medicine, University of Colombo, Sri Lanka

Name: ............................................................................................................

Medical School: ................................................................................................

Address of the Medical School ......................................................................

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Address for correspondence.............................................................................

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Tel No: ............................................. Fax No: ...............................................

Date of Birth ....................... Year of entry to Medical school .........................

Date of commencing clinical work:....................... Hospital: ...............................................

Expected date of commencement of the elective: ...................... Duration: .................

I wish to do following electives:

Check whether you have attached the following:

• a passport size photograph
• a letter from the Dean of your Medical Faculty confirming your student status
• documentary evidence of having commenced clinical work in your hospital
• Tick here if you need information accommodation available

I hereby declare that the information furnished by me in this application are accurate. I agree to remit USD 55 per week as administration charges in respect of the elective attachment referred to above.

Signature: .............................................. Date: ....................................................

Please mail to The Registrar, Medical Faculty, POBox 271, 25 Kynsey Road, Colombo 8, SRI LANKA