Application - Doctor of Medicine and Surgery

Application Form

Medicine
Personal details
APPLICATION COMPILATA
Full name

First name Last name
Date of Birth
Place of birth
E-mail
Secondary e-mail
Telephone
Please provide a telephone number available on WhatsApp
Nationality
Gender
Fiscal code
Passport ID
Passport expiry date

DayMonthYear
The passport must be valid for at least 6 months after the starting date of the programme
Residency address

Address (row 1)

Address (row 2)

City Province

Postal codeState
Current address (if different from the previous)

Address

Address

CityProvince

Postal codeState
Parent full name

NomeCognome
Parent email
Parent telephone

Educational qualifications
Have you already obtained your secondary school diploma?
For UK applicants: GCSE / A-levels / BTEC / Access Course

For German Applicants: Abitur / Class 9 and 10 certificates

For Indian Applicants: Class 10 and Class 12 CBSE

For Italian Applicants: Diploma di maturità o certificato sostitutivo, pagella dell'ultimo anno

For any other countries: valid documents of secondary education
Please upload your school diploma and transcript.

Cancelof
If you have not yet obtained your diploma, please provide the requested details here:
Expected year of graduation Year Diploma Type of diploma
School School City City
Do you want to request recognition of prior learning (RPL)?
Upload here the documentation related to the credits you have earned:

Cancelof
Do you have any English language proficiency certifications?
Upload your English language certifications here:

Cancelof

Special Needs and Learning Support
Does the student have any medical conditions that require assistance or that the College should be informed about?
Please specify any medical conditions that may require assistance:
Upload the medical certificates related to the specified conditions:

Cancelof
Does the student have any specific learning disabilities (SLD) or special educational needs (SEN)?
In which year was the certification obtained?
Upload certifications related to the specific learning disability (SLD):

Cancelof
Notes, comments, and other information:

Documents upload
Attach a copy of a valid identity document (identity card or passport)

Cancelof
Attach a passport-sized photo (front-facing, recent, on a plain light background)

Cancelof
Power of attorney (to ASOMI or third party representing) IF APPLICABLE

Cancelof

DECLARATION

I declare that all the information provided in this application is true and accurate. I also undertake to promptly communicate any changes to the information declared.
Date

DayMonthYear
Date
Signature
Should be Empty:

Application Form