KOREA UNIVERSITY COLLEGE OF MEDICINE

KU Medical Exchange Clerkship Program

Pre-screening Application Form

Personal Information

Last Name : Middle Name :

First Name :
Country : Gender :
Photo Date of Birth :
Institution :
Mailing Address : City State
Country Zip/Postal Code
Tel. . Fax.
Academic Year : /
Expected Year of Graduation :
Phone : Cellular :
E-mail :
Please check! Vegiterian Gluten Free Others ( )
Desired Elective Name & Date : Specify primary and alternative requests.
1) l From to
2) l From to
3) l From to

Language Proficiency :
If you have any of the following exam If you do not have any of exam scores, please
score, please specify in the blanks. indicate your level of language proficiency.
TOEFL : ( ) Korean (Beginner / Intermediate / Advanced )

Others : ( ) English (Beginner / Intermediate / Advanced )

Others ( )

Applicant needs an invitation letter from KUCM : Yes / No

Applicant accomplished prerequisite core clerkship : Yes / No
Applicant wants to stay at universitys dormitory : Yes / No

Letter of Motivation

Registration No. Confirmation

KOREA UNIVERSITY COLLEGE OF MEDICINE

Registration No. Confirmation