Application Form to Udon Thani Rajabhat University

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Faculty of Education
(Photo )
Pre-Service Student Teacher Exchange in Southeast Asia (SEA Teacher
Project # Batch 6)
August 6- September 3, 2018

1. Personal details

Title …………………………………..
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Family name
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First name
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Major…………………………………………… Now studying in grade
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Academic Degree Current Cumulative (G.P.A.)
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Date of Birth …………………………………………………….
Country of birth…………………………………………………
Nationality …………………………………………………………
Passport No……………………………………………………… Issue
Date……………………………Expired Date…………………………..

CURRENT ADDRESS

Address
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City/ State Postcode

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Telephone No. Email Address:
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Name(s) of person for emergency contact:

Related to the applicator as

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Address ……………………………
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Mobile phone:
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E-mail address:
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Line ID:
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Whatsapp :
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Student Health Insurance

Do you have International full health insurance?  Yes  No (if yes, please specify
details.)
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If no, please provide what are your plan and financial plan when you need
medical attention, or when you are
injured or hospitalized.

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Personal health history completed by the student.

Allergies: ………………………………………………………………………….

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Medications:

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Your special request (please specify, dietary specifications, Vegetarian food, etc.)

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Thereby affirm that:

1. All the information in this form is true and correct.
I shall abide by the laws of the Thailand Government and the regulations of
university parties

(Applicant’s signature)
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(Print name)
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(Date)
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Please return this completed form, email attachment to th.nichata@gmail.com

(cc: pornpisut.du@365.udru.ac.th )