Ibn Sina Foundation

Applicant Information

Full Name

Date of Birth

Phone Number

Email Address

Gender

Male

Female

Current Address

Citizenship and Residency

Country of Citizenship

US Visa Status (if applicable)

Type of Visa (if applicable)

Valid Visa/Permit for the US?

Yes

No

Visa/Permit Expiry Date

Purpose

Education and Medical Background

College/University Name

Degree Earned

Graduation Date (MM/YYYY)

Preferred Rotation Dates

Start Date

Preferred Specialty/Department

Required Documents Checklist

CV/Resume

Copy of Passport

Copy of Visa/Permit

Educational Credentials or Enrollment Verification

Copy of ID

Copy of Address Proof

HIPAA and Confidentiality Agreement

Emergency Contact Information

Name

Relationship

Cell Phone

Home Phone

Email

Address

Declaration

I hereby declare that the information provided in this application is true and correct to the best of my knowledge.

Clinical Rotation Application Form