1.

Name of the candidate:

Address:

e-mail address :

2.

Nationality :

  U. S. CITIZEN

3.

Date & Place of Birth :

4.

Passport #

Date and Place of issue :
(Attach six (6) photocopies)

5.

Applicant's address in India during stay :

6.

Name & Address of Medical School (UMMS)

University of Massachusetts Medical School ,

55 Lake Avenue, North , Worcester , MA 01655

7.

Year of admission to UMMS

8.

Examinations passed :

9.

Type of Elective Training the candidate desires to do :

1.

2.

3.

10.

Dates of Elective Training

1.

2.

3.

11.

Recommendation letter from

\Attach six (6) photocopies

Director of International Medical Education,

University of Massachusetts Medical School , Worcester . MA 01655

12.

Bank Draft of Rs. 5000/- drawn in favor of `

Secretary, Medical Council of India ,

Payable at New Delhi .

(Paid by GSMC–UMMS Student Exchange Fund /DJST)

13.

Bank draft For Rs.500/-

Drawn in favor

Municipal Corporation of Greater Mumbai

Payable in Mumbai .

(Paid by GSMC-UMMS Student Exchange Fund / DJST )