INTERNATIONAL FEDERATION

OF MEDICAL STUDENTS‘ ASSOCIATIONS

STANDING COMMITTEE ON RESEARCH EXCHANGE

APPLICATION FORM

Application issued by:

Family name Shafira

First name Karina

Nationality Indonesia
STAMP
Passport number B 0715371 Expiry date 1 April 2020 NORE SIGNATURE

Date of birth 17-07-1998 Sex male female

day month year
Medical student since/
Pre-Med student since 15 8 2016 Clinical student since

Medical school,
Country of study Universitas Andalas, Indonesia

Student’s address:

Street Jl. Bahana No.92 E

City Pekanbaru Postal code 28282

Countr
y Indonesia

Mobile
Phone +6287893632930 phone

country code area code number country code area code number

E-mail karinashafira73@yahoo.co.id Fax

country code area code number

Languages
spoken Indonesian English

Desired native language other languages

(Please try to complete all three choices)
country
Project
1st choice name Egypt in research exchange program

Department City

# of weeks From 1 July 2018 till 29 July 2018

Project
2nd choice name

Department City

# of weeks From till

This application form must be accompanied by all the documents stated in the SCORE database.
 Project
3rd choice name

Department City

# of weeks From till

I need an invitation letter (for visa or other purposes) yes no

I will obtain insurance coverage for the Research Exchange period. Otherwise my exchange will be
cancelled.

Applicant’s
signature Date 24 October 2017

IFMSA SCORE CURRICULUM VITAE

Personal Information
Surname : -
Name : Karina Shafira
Date and place of birth : Bandung, 17 July 1998
Address : Jl, Bahana No,92 E
City : Pekanbaru
Postal code : 28282
Country : Indonesia
Nationality : Indonesia
Telephone : +6287893632930
e-mail : karinashafira73@yahoo.co.id

Education

-Pre-Medical Studies : since : 15 August 2016 to :

I am a student at a premedical level. I provide a copy of my curriculum studi together with this CV. 

-Medical Studies :
Name of University, City, Country : Andalas University, Padang, Indonesia
Medical Student since : 15 August 2016 Clinical Student since :
I have completed _1__ years of my __3.5__ year long course.

Main Medical Fields Studied:

This application form must be accompanied by all the documents stated in the SCORE database.
 studied
Biochemistry 
Biology and Genetics 
Histology 
Anatomy 
Physiology 
Psychology/Sociology 
Microbiology 
Immunology 
Pharmacology 
Pathology 
Epidemiology 
Internal Medicine :
Cardiology : 
Endocrinology : 
Dermatology : 
Haematology : 
Nephrology : 
Infectious Diseases : 
Neurology : 
Pneumology 
Oncology 
General Surgery : 
Orthopaedics and Traumatology : 
Ophthalmology 
Othorinolaringoiatric 
Obstetrics and Gynaecology : 
Paediatrics : 
Radiology : 
Anaesthesiology and Intensive Care : 
Forensic Medicine : 
Psychiatry : 

Others (if you have studied more subjects you do no find on the list
above, please fill spaces below and check them)
_____________________ ð
_____________________ ð
_____________________ ð

Students following an integrated medical degree programme not applying at all with the list above, can send a copy of their
Curriculum Studi, together with this CV. 
-Laboratory or Clinical Electives (in native country or abroad) :

-Name of the Institute/Hospital :

-Department : -Lab exp  -Clinical exp 
-City : -Country : -Since : -to :
-Name of the tutor/professorto contact for further
information concerning you :
-Contact information (tel/e-mai/address) of
above Professor/Tutor :

etc... (reapeat the scheme above for every Laboratory or Clinical Electives you did)

-Other Educational Activities (Lectures, Conferences, Summer Schools, Medical Courses, etc…)

-
-
-

-Languages Spoken

Language : English Level : Basic  Sufficient √ Excellent 

Language : Japan Level : Basic √ Sufficient  Excellent 

This application form must be accompanied by all the documents stated in the SCORE database.
Language : Level : Basic  Sufficient  Excellent 
Language : Level : Basic  Sufficient  Excellent 

Employment History:
(e.g. Part Time Jobs)
-
-
-

Social Skills:
(e.g. Voluntary Work)
- Free Medical Check Up
- Circumcision
- Community service

Technical Skills:
(e.g. Computer Skills)

-Microsoft word,excel and power point

-Making and editing video
-

Hobbies / Interests :
(e.g. Playing a Musical Instrument, Painting or Playing a Sport)

- Reading novel
-Swimming
-Traveling

This application form must be accompanied by all the documents stated in the SCORE database.