Please print first and complete the following application. Scan to [email protected]. Thank you.
Sleep Systems International®
Letter of Application
Personal Information
Name:
Current Address:
Permanent Address:
Telephone number:
Cell number:
Email address:
Age: Gender:
Citizen of what country?
Emergency Contact Information Name:
Relationship:
Address:
Phone numbers: Home: Work:
Cell:
Your Educational Institution Name of University:
Address:
Name of program director:
Have you discussed this program with your program director?
Has your program director endorsed your participation in it?
Degree goal: master’s degree __ specialist degree __ doctoral degree __
When do you expect to complete your degree:
Previous training and/or experience in sleep disorders.
Health
Allergies:
Dietary restrictions:
Chronic medical conditions:
Other health-related information:
English Are you fluent in English? Yes No
Are you knowledgeable and fluent in English medical terminology? Yes No
Number of semesters of English classes
In college: In high school:
Other ways English was acquired:
Estimate your current English language proficiency in
listening comprehension: none, little, some, adequate
speaking: none, little, some, adequate
reading: none, little, some, adequate
writing: none, little, some, adequate
Foreign travel List the countries to which you have traveled and for what length of time:
Please state why you are interested in participating in this program.
Please attach a copy of your vitae to this application.
I hereby request to be considered for participation in the Sleep Systems International program . I certify that the information provided above is accurate and complete.
Signature of Applicant _______________________________ Date _________________
This signed Letter of Application and the three signed forms included in Terms and Conditions of Participation in the Sleep Systems International program should be sent to [email protected]. Program participants will be selected in the order applications are received. Applicants will need to submit program payment within two weeks of acceptance. Applicants will be notified via email regarding acceptance.
Sleep Systems International®
Letter of Application
Personal Information
Name:
Current Address:
Permanent Address:
Telephone number:
Cell number:
Email address:
Age: Gender:
Citizen of what country?
Emergency Contact Information Name:
Relationship:
Address:
Phone numbers: Home: Work:
Cell:
Your Educational Institution Name of University:
Address:
Name of program director:
Have you discussed this program with your program director?
Has your program director endorsed your participation in it?
Degree goal: master’s degree __ specialist degree __ doctoral degree __
When do you expect to complete your degree:
Previous training and/or experience in sleep disorders.
Health
Allergies:
Dietary restrictions:
Chronic medical conditions:
Other health-related information:
English Are you fluent in English? Yes No
Are you knowledgeable and fluent in English medical terminology? Yes No
Number of semesters of English classes
In college: In high school:
Other ways English was acquired:
Estimate your current English language proficiency in
listening comprehension: none, little, some, adequate
speaking: none, little, some, adequate
reading: none, little, some, adequate
writing: none, little, some, adequate
Foreign travel List the countries to which you have traveled and for what length of time:
Please state why you are interested in participating in this program.
Please attach a copy of your vitae to this application.
I hereby request to be considered for participation in the Sleep Systems International program . I certify that the information provided above is accurate and complete.
Signature of Applicant _______________________________ Date _________________
This signed Letter of Application and the three signed forms included in Terms and Conditions of Participation in the Sleep Systems International program should be sent to [email protected]. Program participants will be selected in the order applications are received. Applicants will need to submit program payment within two weeks of acceptance. Applicants will be notified via email regarding acceptance.
