SISM Segretariato Italiano Studenti Medicina
Ufficio Nazionale: Padiglione Nuove Patologie, Policlinico Sant’Orsola, Via Massarenti 9, 40138 Bologna
tel/fax: +39 051 399507; email: [email protected]; web: www.sism.org
Codice Fiscale 92009880375
IFMSA SCOPE CURRICULUM
Personal Information
Surname: ________________________;
Name: ________________________;
Date and place of birth: ________________________;
Address: ________________________;
City: ________________________;
Postal code: ________________________;
Country: ________________________;
Nationality: ________________________;
Telephone: ________________________;
e-mail: ________________________;
Education
Medical Studies
Name of University, City, Country:
_______________________________________________________________________
Medical Student since: ________________________;
Clinical Student since: ________________________;
I have completed ___ years of my ____ year long course.
Biochemistry
Biology and Genetics
Histology
Anatomy
Physiology
SISM Segretariato Italiano Studenti Medicina
Ufficio Nazionale: Padiglione Nuove Patologie, Policlinico Sant’Orsola, Via Massarenti 9, 40138 Bologna
tel/fax: +39 051 399507; email: [email protected]; web: www.sism.org
Codice Fiscale 92009880375
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 Car
Forensic Medicine
Psychiatry
SISM Segretariato Italiano Studenti Medicina
Ufficio Nazionale: Padiglione Nuove Patologie, Policlinico Sant’Orsola, Via Massarenti 9, 40138 Bologna
tel/fax: +39 051 399507; email: [email protected]; web: www.sism.org
Codice Fiscale 92009880375
Others (if you have studied more subjects you do not find on the list above, please fill spaces below and check them):
Laboratory or Clinical Electives (in native country or abroad):
Name of the Institute/Hospital: ________________________;
Department: Laboratory Clinical
City: ________________________; Country: ________________________;
Since ________________________ to ________________________;
Name of the tutor/professor to contact for further information concerning you:
____________________________________________________.
Contact information (tel/e-mail/address) of above Professor/Tutor:
___________________________________________________________________________.
Name of the Institute/Hospital: ________________________;
Department: Laboratory Clinical
City: ________________________; Country: ________________________;
Since ________________________ to ________________________;
Name of the tutor/professor to contact for further information concerning you:
___________________________________________.
Contact information (tel/e-mail/address) of above Professor/Tutor:
___________________________________________________________________________.
Etc... (repeat the scheme above for every Laboratory or Clinical Electives you did).
SISM Segretariato Italiano Studenti Medicina
Ufficio Nazionale: Padiglione Nuove Patologie, Policlinico Sant’Orsola, Via Massarenti 9, 40138 Bologna
tel/fax: +39 051 399507; email: [email protected]; web: www.sism.org
Codice Fiscale 92009880375
Other Educational Activities (Lectures, Conferences, Summer Schools, Medical
Courses, etc…)
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
Languages Spoken
Language: __________________ Level: Basic Sufficient Excellent
Language: __________________ Level: Basic Sufficient Excellent
Language: __________________ Level: Basic Sufficient Excellent
Language: __________________ Level: Basic Sufficient Excellent
Employment History:
(e.g. Part Time Jobs)
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
Social Skills:
(e.g. Voluntary Work)
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
Technical Skills:
(e.g. Computer Skills)
• ___________________________________________________
• ___________________________________________________
SISM Segretariato Italiano Studenti Medicina
Ufficio Nazionale: Padiglione Nuove Patologie, Policlinico Sant’Orsola, Via Massarenti 9, 40138 Bologna
tel/fax: +39 051 399507; email: [email protected]; web: www.sism.org
Codice Fiscale 92009880375
• ___________________________________________________
Hobbies / Interests:
(e.g. Playing a Musical Instrument, Painting or Playing a Sport)
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
This application form must be accompanied by all the documents stated in the SCOPE
database.
Place and date
_____________________
Signature
_______________________