1. Medical Laboratory Training Program
APPLICANT INFORMATION
Please give your full name as it appears on your Passport:
Last Name(s) / Family Name(s) / Surname(s) First Name(s) / Given Name(s)
GenderPermanent Home Address
Nationality at Present Nationality at Birth
Telephone Number Email Address
EMERGENCY CONTACT
In case of emergency, notify:
Last Name(s) / Family Name(s) First Name(s)
Email Address Telephone Number
TRAINING PROGRAM
Please indicate the Training Program you are applying for (check one):
Training
SUMMER 2016
Program
Application
UPLOAD COMPLETED APPLICATION, CURRENT CURRICULUM VITAE (OR RÉSUMÉ),
AND PERSONAL STATEMENT AT WWW.IMRCO.ORG/SUBMIT-APPLICATION
Date of Birth
(MM/DD/YYYY )
APPLYING FOR NEED-BASED SCHOLARSHIP
If "YES", additional financial information must be sent to IMRCo to determine if you qualify for
a need-based scholarhsip. See www.imrco.org/scholarships--sponsorships for details.
Medical Rotation Training Program
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2. CURRENT & OTHER
Current Academy / Employer Specific Role (e.g. student, medical doctor, etc.)
Do you have any mental or physical illness, allergy, disability or condition
that may affect your ability to successfully complete the program, impact
the health and wellbeing of other students or staff members,
require special accommodation, monitoring, treatment or emergency
intervention of any kind during the Program?
(Explain in “Additional Comments” if “YES”)
On a 1-10 scale, how well do you speak English (10 being excellent)?
Do you have a Sponsor?
(Note: Sponsorship is not required. Please include their email if “YES”)
Please include your sponsor's email address here, if "YES"
What are your top areas of scientific or clinical interest? (please list 3 below)
How did you hear about IMRCo?
Additional Comments / Details / Information [Optional]
Please read the “Terms & Conditions”
I have read and accept the “Terms & Conditions”
Signature Date
(MM/DD/YYYY)
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Terms and Conditions ("Terms")
Last updated: July 22, 2015
Please read these Terms and Conditions ("Terms", "Terms and Conditions") carefully before applying to any
Program (“Course”) from, with, or by the International Medical Research Collaborative (“IMRCo”, “IMRC”, "us",
"we", or "our"). The following Terms and Conditions set out the contractual relationship between IMRCo and its
Applicants (“Trainees”) in relation to an IMRCo Program. Applicants should ensure that they read the Terms and
Conditions carefully before submitting their application to IMRCo.
Your Program Acceptance is conditioned on your acceptance of and compliance with these Terms. These Terms
apply to all Applicants.
By accessing or sending us an application you agree to be bound by these Terms. If you disagree with any part of
the terms then you may not apply or submit an application to the IMRCo.