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Joint Master of Health Professions Education (JMHPE)
Program 2014 – 2015
Suez Canal UniversityFaculty of Medicine
Medical Education Department
JOINT MASTER OF HEALTH PROFESSIONS EDUCATION
(JMHPE)
Developed in collaboration between Maastricht University (the Netherlands) and Suez Canal University (Egypt)
APPLICATION FORM2014 – 2015
Please return this form (please fill in electronically and not handwriting) together with the required supporting documents (as clear scanned copies) to:
Medical Education Department Faculty of Medicine Suez Canal University [email protected] [email protected]
And Universiteit Maastricht Department of Educational Development of Research Joint Master of Health Professions Education Programme [email protected]
Joint Master of Health Professions Education (JMHPE)
Program 2014 – 2015
Suez Canal UniversityFaculty of Medicine
Medical Education Department
A. Personal data
Name of Applicant (full name is required):--------------------------------------------------------------------------Date: -----------------------------------------------------------------Family Name/surname ---------------------------------------------------------------------------First Name(s) --------------------------------------------------------------------------------------Title (Prof/Dr/Mr/Ms/Miss/Mrs) --------------------------------------------------------------------------------------Accurate Mailing Address (Please note that we will send the JMHPE educational materials to this address, so please be sure it is accurate and detailed):
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Telephone Number Home -------------------------------------------------------------------------------------- Telephone number Mobile: --------------------------------------------------------------------------------------Telephone Number Work ---------------------------------------Fax No:------------------------------------Email Address (it's better to use Gmail):----------------------------------------------------------------------------------Home Address: --------------------------------------------------------------------------------------
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Date of Birth (dd/mm/yy) --------------------------------------------------------------------------------------Country of Birth: -----------------------------------------------------------------------------Nationality: ----------------------------------------------------------------------Sex: Female Male Name and address of your --------------------------------------------------------------------------------------Next Relative: --------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------Relationship: --------------------------------------------------------------------------------------
Maastricht University, School of Health Professions Education, Joint Master of Health Professions Education ProgrammeP.O. Box 616, NL - 6200 MD MAASTRICHT, The Netherlands Tel.: +31 43 388 5777/8 / Fax. +31 43 388 5639E-mail: [email protected] Website: SHE.Maastrichtuniversity Suez Canal University, Faculty of Medicine, Medical Education Department Round Road, Ismailia 41111, Egypt Tel.: +2 064 3229 129 / Fax: +2 064 3227 426E-mail: [email protected] and [email protected] Website: http://www.themedfomscu.org
Joint Master of Health Professions Education (JMHPE)
Program 2014 – 2015
Suez Canal UniversityFaculty of Medicine
Medical Education Department
B. Language (for non-native speakers only)Level of English proficiency to be: Excellent Good Fair Poor
C. University Education (Start with highest grade obtained, if necessary use additional sheets)
Degree Obtained: --------------------------------------------------------------------------------------Name of University: --------------------------------------------------------------------------------------Address of University: --------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------Studied from (dd/mm/yy): --------------------------------- Until (dd/mm/yy):---------------------------
Degree Obtained: --------------------------------------------------------------------------------------Name of University: --------------------------------------------------------------------------------------Address of University: --------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------Studied from (dd/mm/yy): --------------------------------- Until (dd/mm/yy):---------------------------
D. Work Experience (Start with current positions, if necessary use additional sheets)
Present Post: --------------------------------------------------------------------------------------Job Title: --------------------------------------------------------------------------------------Address of Employer: --------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------Telephone Number at Work: -------------------------------------Fax No: -------------------------------------Describe responsibilities and tasks: --------------------------------------------------------------------------------------
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Length Employment (dd/mm/yy): ------------------------------------- Until (dd/mm/yy)------------------------
E. Financial Support:Maastricht University, School of Health Professions Education, Joint Master of Health Professions Education ProgrammeP.O. Box 616, NL - 6200 MD MAASTRICHT, The Netherlands Tel.: +31 43 388 5777/8 / Fax. +31 43 388 5639E-mail: [email protected] Website: SHE.Maastrichtuniversity Suez Canal University, Faculty of Medicine, Medical Education Department Round Road, Ismailia 41111, Egypt Tel.: +2 064 3229 129 / Fax: +2 064 3227 426E-mail: [email protected] and [email protected] Website: http://www.themedfomscu.org
Joint Master of Health Professions Education (JMHPE)
Program 2014 – 2015
Suez Canal UniversityFaculty of Medicine
Medical Education Department
How do you plan to finance By myself (only approved if guaranteed by a financial your education? statement)
Through my institute/employer (financial statement required)
I have obtained a fellowship from:
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F. Computer ExperienceAre you familiar with the use of?
Word: Yes No
E-mail: Yes No
Internet: Yes No
G. Education in StatisticsDid you have any education in statistics? Yes No
H. Name verification:Write your name as you want it to appear on the certificate.
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Maastricht University, School of Health Professions Education, Joint Master of Health Professions Education ProgrammeP.O. Box 616, NL - 6200 MD MAASTRICHT, The Netherlands Tel.: +31 43 388 5777/8 / Fax. +31 43 388 5639E-mail: [email protected] Website: SHE.Maastrichtuniversity Suez Canal University, Faculty of Medicine, Medical Education Department Round Road, Ismailia 41111, Egypt Tel.: +2 064 3229 129 / Fax: +2 064 3227 426E-mail: [email protected] and [email protected] Website: http://www.themedfomscu.org
Joint Master of Health Professions Education (JMHPE)
Program 2014 – 2015
Suez Canal UniversityFaculty of Medicine
Medical Education Department
I. Enclosures
A coloured scanned copy of your passport (identification page);
A recent coloured passport-size photograph;
Certified photocopies of Higher Education Diplomas;
Certified copies need to be signed by a formal person from the institute you received the Higher Education diploma from. It should be bearing a seal or stamp from the head or registrar and a signature with the name and title of this person).
If you cannot arrange the above then you should certify the diploma by an official person like a notary, someone from the embassy or town hall. Again the diploma needs to have a seal or stamp with a signature and name of this person.
Maastricht University, School of Health Professions Education, Joint Master of Health Professions Education ProgrammeP.O. Box 616, NL - 6200 MD MAASTRICHT, The Netherlands Tel.: +31 43 388 5777/8 / Fax. +31 43 388 5639E-mail: [email protected] Website: SHE.Maastrichtuniversity Suez Canal University, Faculty of Medicine, Medical Education Department Round Road, Ismailia 41111, Egypt Tel.: +2 064 3229 129 / Fax: +2 064 3227 426E-mail: [email protected] and [email protected] Website: http://www.themedfomscu.org