Inquiry Form (Visiting Medical Student Clerkship Program at  Kurume University School of Medicine)
This is the Inquiry Form for Visiting Medical Student Clerkship Program at KUSM (Kurume University School of Medicine)

Students who wish to do the clinical clerkship at KUSM need to fill out this form and have the interview. 
Joining in the interview means starting the "application" for your clinical clerkship at KUSM in earnest, please do not withdraw your "application" after we decide to accept it.

*IFMSA students cannot apply through this form.

1)Clinical Clerkship must be within 4 weeks. We cannot accept any students over 4 weeks.

2)We only accept students from the ECFMG-eligible medical schools.

3)We can issue the acceptance letter after the conference per month if necessary. 

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Email *
①First Name  *
➁Family Name  *
③Email address *
④Your University name
(Only from ECFMG-eligible medical school acceptable)
⑤Which medical department do you want to come? (Except for Psychiatry Medicine)
e.g)①Nephrology ②Orthopedics ③Pediatric Surgery ④Diabetes Internal Medicine               Please write details ↓
×Internal Medicine→Diabetes Internal Medicine
×Cardiology→Cardiovascular Internal Medicine,Cardiovascular Surgery
⑥Scheduled start and end dates   e.g)2023.7.1-2023.7.14 *
⑦What grade and Which department (faculty,major) are you in? e.g) Sophomore, School of Medicine
⑧I am aware that my application through this form has no relation to IFMSA. *
⑨Even if you apply on this application, there are possibilities to be denied because of the over capacity. You will be asked to submit the Immunization form designated by Kurume University and Chest X-ray image in the selection of process. *
⑩Do you want us to book the domitory, Galenus ( ? (JPY4,200~4,800 including 2 meals per day) If so, when do you want to check in and check out? In case there are no vacancies, you have to book the hotel in Kurume by yourself. *
⑪You have to pay the insurance fee JPY1,320 for your clinical clerkship by cash at the counter of KUSM on the start date of your program. *
⑫Do you need Japanese Visa to come to Japan?( *
⑬If you are not a robot, please write  "KURUME" below. *
⑭Nationality *
⑮Biometric Gender *
⑯Any additional comment? ( allergies, religious consideration etc )
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