APPLICATION TO SPEND MEDICAL COLLEGE ELECTIVE PERIOD AT

WANLESS HOSPITAL, MIRAJ MEDICAL CENTRE, MIRAJ.

1. Name ______________________________________________ Age _____________

2. Address : ______________________

______________________

______________________

3. Medical College _______________________________________________________

4. Year in medical college _________________________________________________

5. Years of clinical experience ______________________________________________

6. Year you expect to complete your medical course _____________________________

7. Dates of elective period _________________________________________________

8. Why do you want to come to Miraj? _______________________________________

_____________________________________________________________________

_____________________________________________________________________

9. Church attend _________________________________________________________

10. Are you a member of the Student Christian Movement or other Christian youth

group? ____________________________________________________________

___________________________________________________________________

___________________________________________________________________

11. Special interests, skills, hobbies _________________________________________

___________________________________________________________________

___________________________________________________________________

Date : _____________________ Signature _____________________

Please complete and send with one recommendation from the Dean of your medical college and one from the Pastor of your Church to:

The Director

Wanless Hospital, Miraj Medical Centre,

MIRAJ 416 410 Maharashtra, India.