IMIM Application Form Return via e-mail to imim@rug.nl www.innovativemedicine.eu Deadline: 1 February 2016 Personal Information Last Name (as in your passport) First Name(s) (as in your passport) st Initials (1 letter of each name) Male Nationality/ies Country of citizenship Date of Birth (DD/MM/YYYY) Place of Birth (City, Country) Back-up e-mail Contact Details Address for Correspondence Street addresss Additional address details Postal Code State/Region (optional) City Country Mobile Phone Phone 2 Contact in case of Emergencies Relationship to you City, Country Phone 1 (incl. country code) Phone 2 (incl. country code) E-mail Back-up e-mail (optional) Page 1 of 5 Female
Preferences & Scholarship Groningen Heidelberg Uppsala EU/EEA Are you a resident of the EU or EEA (=EU+ FYRoM, Iceland, Liechtenstein, rway, Switzerland, Turkey)? non-eea Yes, specify below Have you participated in any other Erasmus Mundus or Erasmus+ master programme in the past? A limited number of scholarships will be available for students participating in IMIM (see www.innovativemedicine.eu). Only the top-ranked applicants are eligible. Yes Should this application also be viewed as an application for an IMIM scholarship? Yes, specify below Will you also apply to other types of funding? At which IMIM partner would you like to spend your first semester? Degree Information Undergraduate (BSc/MD) Degree Information Official degree programme name (original language) Degree name in English Institution Name Institution Country Official duration degree programme Enrolment Date (MM/YYYY) Graduation Date or expected Graduation Date (MM/YYYY) GPA* (score/scale, e.g. 3.5/4) or percentage Ranking in class Top-1-2% Top-5% Top-10% Top-25% Other, namely: Top-25% Other, namely: Other Degree (optional) Official degree programme name (original language) Degree name in English Institution Name Institution Country Official duration degree programme Enrolment Date (MM/YYYY) Graduation Date (MM/YYYY) or expected Graduation Date GPA* (score/scale, e.g. 3.5/4) or percentage Ranking in class Top-1-2% Any other degrees? Yes Top-5% Top-10% If yes, list details in your CV Page 2 of 5
Language Skills Enter your score for the English-language tests below. Additionally, you have to upload a pdf copy of your test results with your online application. Some applicants may be excused from this requirement (see guidelines here). If you belong to this group, indicate this in the other proof field below. If you do not yet have your test results, indicate the date of your test and when you expect the results. Test name (e.g. TOEFL) Score Other proof Expected test date/test results (DD/MM/YYYY) References Referees provide important feedback for your admission to IMIM. All references are confidential and should be sent to us directly by the referees. You should provide information on your referees below. It is your responsibility to ensure that your referees send us their feedback on you before the deadline of 1 February 2016. The referees should use the reference form available on the IMIM website. Please forward this form to your referees. Anybody who can supply us with detailed information on your capabilities, motivation and background you may consider as a potential referee, provided that this person only has had a professional relation with you (e.g. lecturers, supervisors, mentors, employers...). Perhaps needless to say, but relatives and partners are excluded from this category. In short: - We only accept reference forms sent directly by referees to imim@rug.nl before the deadline of 1 February 2016 Reference forms sent by you as an applicant will not be accepted First Referee Second Referee Third Referee (optional, but recommended) Page 3 of 5
Official Statement I certify that I have read all application instructions and that the information I have provided is true and complete. I understand that misrepresentation may be a cause for cancellation of my admission or appointment. Submission of this application in no way guarantees my right to participate in the IMIM programme. I understand that all documents I submit as part of this application become the property of the IMIM Consortium. My application will only be made available to the IMIM Consortium and the Admissions office of the University of Groningen. I agree (tick box) Name Date Completed Page 4 of 5
Supporting Documents All application materials should be submitted online via the application system to be accessed via www.innovativemedicine.eu. Each document should be attached as a single pdf, each with a maximum size of 2MB. These PDFs should have the following names (in capitals what you need to complete): - YOUR LAST NAME_Application form YOUR LAST NAME_CV YOUR LAST NAME_Motivation YOUR LAST NAME_Diploma YOUR LAST NAME_Transcript YOUR LAST NAME_English YOUR LAST NAME_Passport YOUR LAST NAME_Optional_TYPE OF DOCUMENT After you submit your online application, you should receive an automated confirmation message with your unique application code. If you have questions about your application, please mention this code. In case you do not receive an automated message (check also your spam-folder), contact imim@rug.nl. Check List Attached Document Comments and instructions Curriculum Vitae Include academic degrees, work/volunteer experience, conference presentations, publications and special skills Letter of motivation This letter is very important. See Diploma(s)/Degree(s) Academic Transcripts A listing of all courses and corresponding grades and an explanation of the grading system Only university degrees, no secondary/high school degrees! If you have not yet received your degree, send a statement letter with the expected graduation date signed by your Home University English proficiency test, if applicable Copy of passport(s) Additional documentation If your application is incomplete, provide an explanation here. If a document is missing without an explanation, your application may not be taken into account. Page 5 of 5