□Medical Student

Name Category □Nursing Student Nationality

(First, Last) □Others （ Profession ：
________）

Date of
Basic Information of Applicant

ID (Passport)
Gender □Male □Female
Number birth
(yyyy,mm,dd)

School Department Grade

Clerkship From Year____Month____Day____To

Period Year____Month____Day____，Total:___Years___Months____weeks
□Chang Gung University （ Chang Gung University of Science and
Commission Technology）Exchange Student
□Recommendation from other university or academy institution
Type
□Recommendation from first order supervisor or above, recommend supervisor:
________________
Attached □Training program □Personal curriculum vitae □Certificate of Student Status (copy)
Document □Passport (copy) □Recommendation letter
1、□Agree clerkship training
Acceptance Department

□Unable to arrange training，description：

2、Clerkship Supervisor in training department：________________________________________

3、□ Charge Training Tuition Fees NT$ dollars/month □ Free of Charge

4、 Other Applications:□ Single Dormitory □ Temporary ID card □Access Card, Operation

Room Access
Supervisor （ Department Chairman ） ： ___________ Supervisor （ Division Chairman ） ：
______________
1、Clerkship Review：
□Foreign university approved by our Ministry of Education, agree the application of clerkship
Medical Education

□Foreign university not approved by our Ministry of Education, reject the application
□Others，description：
Department

2、Other applications approved：

□ Free Single Dormitory （ exchange student of our institution ） □ Charge Single
Dormitory（not exchange student of our institution）
□ Temporary ID card □Access card

Chairman：___________ Supervisor：__________ Handled by：__________

 □Approve □Not approve，Description：
Dean

Dean：________________

Clerkship Application Form for Foreign Medicine Related Student

Branch：□Linkou □Keelung □Kaohsiung □Chiayi Application Date: Year_____ Month_____ Day___

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