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MAH Application Form

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30/04/2016

Applicant details

Applicant details
* Required

1. Last Name *

2. First Name *

3. Nationality *

4. Date of birth *
Example: December 15, 2012

5. Gender (M/F) * : ....................

6. Address *

7. Postal code *

8. City *

9. State/Province *

10. Country *

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Applicant details

11. Email *

12. Skype username

13. What is your time difference to GMT?

14. Phone number (including area code) *

15. Fax number

16. Name of college *

17. Year of study *

18. What language(s) are your classes taught in? *

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Applicant details

19. What language(s) do you speak fluently? *

20. What language(s) do you speak moderately?

Project details
21. Length of project requested (min 4
weeks) *

22. Dates (or estimated months) during which project will take place *

23. Project location (if already known)

24. Estimated budget (US$) *

Practice type desired (rank numerically, with 1=most


desired)

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Applicant details

25. University *

Medicine
26.

Surgery

Practice *

Small
Animals
Pathology
Large
Animals
Microbiology
Equine
Parasitology
Exotics
Other
Mixed
Public Health
Other

IVSA and other activities


27. Which IVSA member organisation are you part of? (if you are an individual
member, please state so) *

28. What position do you hold within your member organisation? *


Mark only one square.
President
Exchange Officer
Member
Other

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29. What IVSA events have you attended before? (Symposium, Congress, Exchange) *

30. Are you involved in other associations/organisations/extracurricular activities? *

31. Have you been involved in any volunteer work before? *

32. I hereby confirm I have read and understand the rules for individual exchanges and
agree to abide by them *
Yes
33. Date application completed *
Example: December 15, 2012

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