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)
Contact e-mail
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
Name (first, last)
Relationship to you
City, Country
Phone 1 (incl. country code)
Phone 2 (incl. country code)
E-mail
Back-up e-mail (optional)
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Female
Preferences & Scholarship
Groningen
Heidelberg
Uppsala
EU/EEA
Are you a resident of the EU or EEA (=EU+ FYRoM, Iceland, Liechtenstein, Norway, Switzerland, Turkey)?
non-EEA
Yes, specify below
Have you participated in any other Erasmus Mundus or Erasmus+ master programme in the past?
No
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?
No
Yes, specify below
Will you also apply to other types of funding?
No
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%
No If yes, list details in your CV
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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
Name (first, last)
Position
Name Institution
Country Institution
Contact e-mail
Second Referee
Name (first, last)
Position
Name Institution
Country Institution
Contact e-mail
Third Referee (optional, but recommended)
Name (first, last)
Position
Name Institution
Country Institution
Contact e-mail
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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
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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.
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