Telephone: Fax: Year of study: Languages spoken:

Sex: male/female

Telephone: Fax: Year of study: Languages spoken:

Type of exchange (underline): Unilateral Bilateral

Dental School & Address:

Remarks (invitation paper requirements/other):

I am / am not willing to go anywhere else if the country of choice is not obtainable.

Dates for exchange (Arrival/Departure)

From d / m / y to d / m / y

I would prefer to do clinical work/observe in the department of:

APPLICATION FOR IADS EXCHANGE Name: Date Of Birth: d / m / y Sex: ❑ M Address (during term-time):	PHOTO

Telephone:

Email (in CAPITALS):

Address 2 (during holidays):

	1st choice	2n d choice	3r d choice
Country
Dental School

Dean’s signature

School stamp (in space below)

Applicant’s signature

National Exchange Officer’s signature

Date: _____d/_____m/_____y

Дата добавления: 2015-08-27