SIAD1 Form- Siriraj Scholarship for ASEAN&Developing Countries

STAD1-Form

This is the application form for Siriraj Scholarship for ASEAN and Developing Countries, 2024-2028.
Please choose the type of scholarship you apply for:(The definition for these 2-type of schlorship shown on the PROJECT OUTLINE; https://drive.google.com/file/d/1DJ0SwMNdp7eIBDK6IlnqL9S3XQtsskgQ/view)**

Scholarship for Short -Term Training (ST)Scholarship of Potential Candidate for Postgraduate Education Training Program (PC)

NOTE:

1. There are 4 rounds of admission available as follows:

Round	Deadline for submission
1st round	January 31st
2nd round	April 30th
3rd round	July 31st
4th round	October 31st

2. To visit our website to explore the additional information via https://www2.si.mahidol.ac.th/en/ir/asean-scholarship/

Required Documents:

1. Curriculum Vitae (CV) or Resume

2. The certificate of medical degree (or equivalent)

3. Valid Practicing License

4. A Letter of Certification or Recommendation from your institution

5. COVID-19 vaccination certification showing at least 3 doses

6. A recent photo with your full face looking straight at the camera like a passport photo (sample) in *.pdf or *.jpg file

7. Personal Statement/ Motivation Letter; this part will provide the information for the department your interest and your background relating to them, etc.

SECTION 1: COMMITMENT

Before completing the application form, applicants are strongly advised to review allthe program's terms and conditions carefully. By signing the application or anyrelated document, the applicant confirms their complete understanding andunconditional acceptance of all rules, requirements, responsibilities, andconditions governing participation in the program. It shall be deemed that theyhave given their informed consent, and no claims of unawareness or disagreementshall be considered thereafter.
Signature*

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SECTION 2: PERSONAL INFORMATION
Name*

PrefixFirst NameMiddle NameLast Name
Date*

MonthDayYear
Date
Nationality*
Age*
Sex*

FemaleMale
Passport Number*
Passport Expiry Date*

MonthDayYear
Date
Maritial Status

SingleMarriedWidowedDivorcedOther
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Media*

LineWhatsappFacebookWeChatOther
Social Media ID*
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Number*
Please enter a valid phone number.
Office Fax
Emergency Contact Information

Emergency contact is a person to be notified in case of emergency
Emergency Contact Name*

First NameMiddle NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Emergency Contact Email*
example@example.com
Health information

All information given will be kept in confidence, please, respond freely to the questions
Blood Type*

ABOABOther
Do you have any underlying diseases?*

YesNo
If 'Yes' please specify
Are you taking medications at the moment?*

YesNo
If 'Yes' please specify
Do you have drug allergy?*

YesNo
If 'Yes' please specify
SECTION 3: LANGUAGE PROFICIENCY

Kindly indicate the languages you are able to communicate in and specify your proficiency level for each language.
1st Languages*
2nd Languages
SECTION 4: EDUCATION

Please list the information about your educational background by providing the details in order from the most recent to the earliest. You can add up to 3 institutions.
Institution #1
Institution #1 name*
City and country*
Period of study (e.g. August 2016 - March 2023)*
Qualification obtained
Major fields of study*
Language used*
Institution #2
Institution #2 name
City and country
Period of study (e.g. August 2016 - March 2023)
Qualification obtained
Major fields of study
Language used
Institution #3
Institution #3 name
City and country
Period of study (e.g. August 2016 - March 2023)
Qualification obtained
Major fields of study
Language used
SECTION 5: WORK EXPERIENCE

Beginning with your present post, provide precise details of your responsibilities and activities and describe what you do. Give particular attention to any duties related to your qualifications for this scholarship or to your need for the study proposed.
Current Post
Period of your post (e.g. March 2016 - present)*
Title of your post*
Name of the employer and/or institute*
Address of the employer and/or institute*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type of employment*
List of you specific duties*
Previous Post
Period of your post (e.g. March 2016 - present)
Title of your post
Name of the employer and/or institute
Address of the employer and/or institute

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type of employment
List of you specific duties
SECTION 6: STUDY PLANS AND OBJECTIVES
Specify the field or subspecialty you wish to pursue under this program*

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Explain why you want to study this field and describe your specific goals for this training.*

0/0
On completion of my study at Faculty of Medicine Siriraj Hospital, Mahidol University, I hope to be able to:*

0/0
SECTION 7: REQUIRED DOCUMENTS
1. Curriculum Vitae (CV) /Resume*

Candidates whose official university documents are in languages other than English or Thai must submit copies of both the original documents and certified English translations.
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2. The certificate of medical degree (or equivalent)*

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3. Valid Practicing License*

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4. A Letter of Certification or Recommendation from your institution*

Include the organization’s logo and the signature from the Dean or the Director or the authorized person of institute of the applicant’s institute
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5. COVID-19 vaccination certification showing at least 3 doses*

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6. A recent photo with your full face*
7. Personal Statement/ Motivation Letter

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