Sir Run Run Shaw Hospital

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Application for Acceptance of International Fellowship

Date Submitted

PERSONAL DATA
Name	First	*	Middle	*	Last	*

Gender*	male Female	Telephone	*
Birthdate		Fax
Nationality		E-mail	*

Present Address	Street	*
	City	*
	State/Province	*
	Postal Code	*
	Country	*

PROGRAM INFORMATION
Preferred Specialty	Duration (weeks)
1. *	*
2.
3.

SRRSH does not have pediatrics. If you choose internal Medicine, inform us of the desired subspecialty.

Requested Starting Date	Ending Date	Total Duration (weeks)

EDUCATION RECORD			Please complete information relevant to your education
Dates			Institution	Degrees and Honors
Month and Year			College/University
*	to	*	*	*
	to
Month and Year			Graduate School
	to
Month and Year			Medical School
	to
	to		Internship
			Location
	to		Residency
			Location
Month and Year			Fellowship
	to

Please state the learning objectives of your elective:

Upload Attachment

CV		Select
Recommendation		Select

CONTACT US International Healthcare Services

- Qingchun Campus:
Out-patient Appointment Phone: 86(571)86006118
Inpatient Phone: 86(571)86006961
E-mail: isc@srrsh.com Webpage: www.srrsh.com
Out-patient Address: 11th Floor, Tower Ⅵ,3 East Qingchun Road, 310016, Hangzhou
Inpatient Address: 11th Floor, Tower Ⅱ, 3 East Qingchun Road, 310016, Hangzhou
- Qiantang Campus:
Out-patient Appointment Phone: 86(571)87887168
E-mail: iscxs@srrsh.com Webpage: www.srrsh.com
Out-patient Address: 5th Floor, Inpatient Building, Xiasha Road, 310018, Hangzhou

Abroad Leaning/Training (International Doctors/students)

Address: 7th Floor, Tower Ⅶ, 3 East Qingchun Road, 310016, Hangzhou
Phone:86(571)86006687
E-mail:wangmy@srrsh.com
Making An Appointment

Administrative Affairs

Address: 7th Floor, Tower Ⅶ, 3 East Qingchun Road, 310016, Hangzhou
Phone:86(571)86006436/86(571)86006613
E-mail:Info@srrsh.com
Fax:Info@srrsh.com

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