SVS01_APPLICATION FORM_SIRIRAJ INTERNATIONAL VISITING SCHOLARS

SVS01_APPLICATION FORM_SIRIRAJ INTERNATIONAL VISITING SCHOLARS
Please answer each question clearly and completely. Detailed answers are required to ensure the most appropriatestudy arrangements.
Personal Info
Name*

TitleFirst NameMiddle NameLast Name
Birth Date*

DayMonthYear
Current Job Position*
Area of Expertise*
Contact Info
Work Address*

Institution's Name

Street Address

CityState / Province

Postal / Zip CodeCountry
Office Telephone*

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Telephone*

Area CodePhone Number
Email Contact*
example@example.com
Emergency Contact Info*
Visiting Info
Proposed Start Date*

DayMonthYear
Proposed End Date*

DayMonthYear
Proposed by the Department of*
Please tell us about your competency, experience, and relevant background related to the proposed department.*
Would you contribute to the Faculty of Medicine Siriraj Hospital in the area of teaching? If yes, please provide a detailed explanation of how you would contribute.*
Would you contribute to the Faculty of Medicine Siriraj Hospital in the area of research? If yes, please provide a detailed explanation of how you would contribute.*
Would you contribute to the Faculty of Medicine Siriraj Hospital in the area of medical service? If yes, please provide a detailed explanation of how you would contribute.*
Personal Documents
Formal Portrait Photo*

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CV or Resume*

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Copy of Passport (Biopage)

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During your visit at Siriraj, will you be performing examinations, case demonstrations, consultations, or research that involves direct interaction with patients?*
Medical license in your home country*

Please note that the document must be issued by a governmental authority, and it should be valid for the entire duration of your visit at Siriraj.
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Proof of Specialty *

Please note that the document must be issued by a governmental authority or by an officially recognized professional college/society, and it should be valid for the entire duration of your visit at Siriraj.
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Please click the following link to download the consent form.

https://drive.google.com/file/d/1DvHwmNjWR_43PjqtTUrxe3mOJhjn6U0R/view?usp=sharing

After downloading, kindly complete the form by either printing and signing it by hand or applying a digital signature. Once signed, please scan or take a clear photo of the document (if signed by hand) or save it as a PDF (if signed digitally), and then upload the signed form in the attachment box provided below.
Consent Form

Please find the attached form from the provided link: https://forms.gle/hhtYfchHLkFi4KaV6
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By submitting this application form, the applicant acknowledges and agrees to the following terms and conditions:

Collection and Use of Personal Data
The information provided in this application form, including personal data, will be collected, used, and processed for the purposes of evaluating the application, verifying the applicant’s identity, and communicating regarding relevant matters.
Legal Basis for Processing
The processing of personal data is conducted in accordance with Thailand’s Personal Data Protection Act (PDPA) and other applicable laws. The applicant's data will only be used for the specified purposes and will not be disclosed to third parties without prior consent, except where required by law.
Data Retention and Security
The applicant’s personal data will be retained for the necessary period in accordance with applicable regulations. Appropriate security measures will be implemented to protect the data from unauthorized access, alteration, or disclosure.
Rights of the Applicant
The applicant has the right to access, correct, or request the deletion of their personal data, as well as the right to withdraw consent at any time, subject to legal limitations. Requests can be made by contacting [insert contact details].
Consent
By signing and submitting this application form, the applicant confirms that they have read, understood, and agreed to the terms stated above, including the collection and use of their personal data as described.
Signature*

Clear
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SVS01_APPLICATION FORM_SIRIRAJ INTERNATIONAL VISITING SCHOLARS

Personal Info

Contact Info

Visiting Info

Personal Documents