AF Number

Date Taken
Date Collected

All sections must be filled accordingly. Failure to do so may lead to disqualification.

PERSONAL INFORMATION
First Middle Last
Name

Nationality Gender
Day Month Year
Date of Birth

Nationality
Native Others
Languages Spoken

Number Valid Until (dd/mm/yyyy)

Passport*

*If you do not have passport or your passport is expired please tell your LEO.

CONTACT INFORMATION
Origin Address
City, Province Postcode
Current Address
City, Province Postcode
Mobile Home
Phone

AN AFFILIATION WITH:
 Email
Failure to provide valid contact information might cause serious problems in the future. Please make sure
that both your phone number and email are working properly.

EDUCATION
University
Medical students since Clinical students since
Enrollment

DESIRED COUNTRIES
Priority*
Level 1

Level 2

Level 3

Others

Please ask your LEO about the countries level and how to choose them.
“Others” is two countries you’d like to be placed in, in case the worst possibility occurs.
Make sure you are aware of the Exchange Conditions of your country choices.
*Please write your sequence of priority.

EXCHANGE DATE ESTIMATION

Please carefully estimate your preferred date of departure.
Providing your date estimation might help us avoid cancellation in the future.

AN AFFILIATION WITH:
 Documents Attached (filled by LEO or SCOPE members in-charge)
Motivation Letter
Curriculum Vitae

I hereby declare that all information above is correct and I agree to accept any of those six countries I have
chosen. If I fail to do so, I will either find a substitute or pay compensation fee to SCOPE CIMSA.

…………………….. , ………………………
Applicant, Local Exchange Officer,

………………………………… …………………………………

AN AFFILIATION WITH: