ASIAN MEDICAL STUDENTS’ ASSOCIATION (AMSA)

FACULTY OF MEDICINE
HALU OLEO UNIVERSITY
Membership and Development (MnD)

APPLICATION FORM

Personal Detail

Full Name :
Nick Name :
Gender :
Status :
Date of Birth :
Nationality :
Address :
Mobile Phone :
E-mail :
Spoken Language :
Written Language :
Other Interest/Skills :

Formal Education/Qualification
Senior High School :
Junior High School :

Organization in FK UHO

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Contact Person AMSA UHO

Likvy Perdani Malik (+6281354683018/likvyperdanii) AMSA UHO
Delyana Brilian Hamra AMSA UHO
(+6282195001759/dheahamra) @AMSAUHO
 ASIAN MEDICAL STUDENTS’ ASSOCIATION (AMSA)
FACULTY OF MEDICINE
HALU OLEO UNIVERSITY
Membership and Development (MnD)

Other Activities

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Academic Achievements (in last 5 year)

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Motivation Letter (please explain your motivation why you choose AMSA than the other)

Contact Person AMSA UHO

Likvy Perdani Malik (+6281354683018/likvyperdanii) AMSA UHO
Delyana Brilian Hamra AMSA UHO
(+6282195001759/dheahamra) @AMSAUHO