Erasmus International Master program Health Information Management. Application Form

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1 Erasmus International Master program Health Information Management Application Form Information for applicants Please attach a recent passport-size photograph and a copy of your passport to the application form. Copies of academic records from all colleges or universities that you have attended must be submitted. The program management can ask for certified copies. Please attach translations of records if they are in languages other than English, Dutch, German or French. Candidates should indicate their proficiency in English honestly. In case of doubt, the program management can ask candidates to take a TOEFL test. Candidates should provide one statement of support from their sponsoring organization. The program management reserves the right to contact your sponsor for further information regarding your application. When the application is complete, a program representative will hold a telephone interview with the applicant. After this, the applicant will be informed by the program management about admission. For enquiries, please contact the program organisation: Institute for Health Policy and Management Erasmus Centre for Management Development in healthcare Attn. Ms. Marianne Breijer-de Man (room L3-089) P.O. Box 1738 NL-3000 DR Rotterdam The Netherlands Phone: +31 (0) Fax: +31 (0)

2 Erasmus International Master program Health Information Management Application Form I would like to be considered as a candidate for the Erasmus International Master program Health Information Management Program starting in March Name First/Middle/Last/Family name Commonly used first name Male / Female Home address Street City Postal Code Country Home telephone Mobile phone address Business details Current position Company Work address Street PO Box City Postal Code Country Business telephone Business fax Business

3 Personal information Date of birth Place of birth (City/Country) Nationality Other citizenship Marital status Number of children Work experience Number of years of full-time work experience by the start of the program Education Please list in reverse chronological order all undergraduate and graduate institutions from which you have received an academic degree (include copies)

4 Please list all pre-university/pre-college institutions (including secondary schools) from which you graduated and other universities, colleges, institutions attended for non-degree courses Academic honors or awards received Extracurricular activities

5 Postgraduate work Describe any additional qualifications you have for advanced study or research. List the titles and dates of published work, if any. Other qualifications List any other professional qualifications you have, membership in professional or civic associations, special projects in which you have participated, etc. Language proficiency Please indicate your language proficiency (Native, Fluent, Average or Basic) English French German Spanish Other: Career history Current employer Sector of activity Number of employees Country of operation Division/department Role and responsibilities

6 Does your current employer know that you are applying for the EIMHIM? Previous employers (in reverse chronological order) 1. Name Sector of activity From (date) until (date) 2. Name Sector of activity From (date) until (date) 3. Name Sector of activity From (date) until (date) Financing your studies How do you expect to finance your studies? Applying to employer for financial support Partial sponsorship from my employer Full sponsorship from my employer Bank loan Own savings Other Marketing information How did you learn about the EIMHIM? an advertisement (which journal) an article, editorial or press release in at a congress (which) internet (website name) an educational guide, namely. an alumnus/students recommendation. a recommendation by your company s Management Development Department or HR Department.. advice of a professor other sources

7 Applicants agreement I certify that the information given is complete and accurate to the best of my knowledge. I realize that all materials submitted in support of my application for admission become the property of the Erasmus University. The program management may verify any and all parts of my application form materials. Applicants signature Place Date Sponsorship Please list below the name and address of a person who can speak on behalf of your sponsoring organization in order to inform us about your intellectual and managerial skills and potential. Include the sponsorship form with your application. Name Address Erasmus International Master program Health Information Management

8 Erasmus International Master program Health Information Management Sponsorship Form This form should be filled out by an authorized representative of the organization sponsoring the applicant. Applicant name. Date of birth To the sponsor: The above named applicant has applied for admission to the Erasmus International Master program Health Information Management. The objective of the program is to develop managers with the knowledge and skills to initiate and implement innovative forms of healthcare delivery through a continuous process of organizational change and information management. Participants can continue working during the program. The information you provide is considered to be a very important part of the admission process. Please fill out this form and hand it in a closed envelope if you desire- to the applicant, who will submit it together with the application forms. Without your consent, your comments will not be released to the applicant. How long and in what capacity have you known the candidate? What is your opinion of the candidates motivation and career potential?

9 What do you consider as his or her principal qualities or weaknesses? Please comment on the candidates interpersonal skills Do you support the candidates application? Strongly support Support Support with reservations Do not support To what extent will your company or institution support the applicants financially and/or otherwise (study time)? Sponsor: Name Company or institution Street/City Postal code/country Work telephone address Erasmus International Master program Health Information Management

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