PART D: Elective Choices (Please tick the choice.)
From (date/ month/ year) …………………. to ………………………
Indicate applicant's elective Department and duration.
( ) Anesthesiology.....……...…………….. weeks
From (date/ month/ year) …………… to ............…………
( ) Forensic Medicine .................................. weeks
From (date/ month/ year)……………. to............…………..
( ) Medicine …………………..……….. weeks
From (date/ month/ year).......……… to ………………
( ) Obstetrics and Gynecology …………………..……… weeks
From (date/ month/ year) .......……… to ………………
( ) Ophthalmology …………………. weeks
From (date/ month/ year) …………... to ………………
( ) Orthopedics ……………….…… weeks
From (date/ month/ year) ………….. to ………………
( ) Otorhinolaryngology
From (date/ month/ year) …………. to ………………………
( ) Pediatrics ………………………... weeks
From (date/ month/ year) ………… to ……………………
( ) Psychiatry ………………………… weeks
From (date/ month/ year) ………… to ……………………
( ) Radiology …………………….……… weeks
From (date/ month/ year) ………….……… to …………………
( ) Rehabilitation Medicine ………………………… weeks
From (date/ month/ year) .......…….. to ……………………
( ) Surgery (at least 4 wks) ......……………………..... weeks
From (date/ month/ year)....……………… to ............………
( ) Other ………………………... weeks
From (date/ month/ year) ……………….... to ..…………………
Expected arrival in Khon Kaen:
(date/ month/ year) ………………………