Wilson Medical Exchange – Apply

Please answer the following questions in English except where otherwise noted:

Applying for which program?:*

Are you a Teacher or a Student?*
TeacherStudent

Chinese Name:*Please enter your Chinese name in both 汉字 and Pīnyīn.

English Name:*Please enter your English first and last name. If you do not have an English last name, use your Chinese Surname (example: Lisa Wu).

Nationality:*Please enter your majority or minority.

Citizen ID Number:*Please enter your 18-digit Chinese Citizen Identity Number.

Registered City of Permanent Residence:*Please enter the city where you are registered as a permanent resident.

Gender:*
MaleFemale

Date of Birth:*Please enter your birthdate in the form yyyy-mm-dd (ex: 1997-12-02).

Mobile Phone:*Please enter your 11-digit mobile phone number.

Social Network:Optional: Please enter your WeChat and/or QQ IDs.

Email:*Please enter your email address in the form "name@example.com".

University:*Please enter your university's name and campus.

Academic Major:*Please enter the academic major that you are pursuing or have attained.

Type of Student:*

Please Specify:*

Year in Degree Program:*

Employer:*Please provide the name of your current employer.

Years of Teaching Experience:*

Types of Teaching Experience:*Please list the types of teaching you have performed (Ex: Elementary, High School, University, etc.)

Type of career you intend to pursue in the future (be specific):*Please share the type of career you plan to pursue in the next 3-5 years.

Please list three other career interests:Please share other career-related fields, roles or responsibilities you want to explore.

Do you currently have a valid passport?*Please indicate whether you have a passport that is valid for at least 6 months after your desired period of participation in this program.
YesNo

Do you currently have a valid US visa?*
YesNo

Have you ever been DENIED a visa to the United States?*
YesNo

Please list any of your allergies or medical conditions:*Please indicate any allergies or medical conditions that may impact your participation in this program.

Why are you interested in this exchange program?*

Why do you want to pursue the career you indicated above?*

What is a significant challenge facing the Chinese professionals in your field, and how could you help improve it?*

How did you hear of the program?*Please share who referred you to this program, or where you heard about it (ex: A friend(name), WeChat, Internet, etc.)

Code of Conduct

If I am accepted to the CONNECT Exchange (CE) program, I agree to the following:

  • I will pay all program fees to 联星出国服务(南京)有限公司 on time.
  • I will NOT become intoxicated, take illegal drugs or pursue romantic relationships during the exchange.
  • I will NOT drive in America.
  • I will submit a criminal background check to 联星出国服务(南京)有限公司.
  • I will abide by all U.S. laws and regulations.
  • I will have a submissive attitude toward CE hosts, professionals, program leaders, and representatives.
  • I will have a respectful attitude toward Americans and their culture.
  • I will report concerns to CE program leaders and CONNECT staff.
  • I will accept city placement and travel arrangements made by the CE program leaders and CONNECT staff.
  • I will fully participate in all CE activities.
  • I will sign a contract acknowledging the risks and indemnifying, defending, and holding harmless 联星出国服务(南京)有限公司, its trustees, officers, employees, agents, volunteers and assigns for any claim arising out of or incident to my participation in the exchange, except for claims arising out of the sole negligence or willful misconduct of 联星出国服务(南京)有限公司.

If I do not abide by the above guidelines, I forfeit my participation in the Connect Exchange and will bear the financial burden for my actions including the program fee and an early return flight back to China if the program leaders determine an early return is necessary.

By checking this box, I agree to all of the above:*
I agree

Personal Interview: The final step in the selection process is a personal interview in English with an exchange program representative. If chosen for an interview, you will first be contacted with appointment details.