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.�