FOR BOARD USE ONLY!

☐    Photo

☐    Paid

☐    Card Made

☐    Card Received

☐    Entered into list of members


                                         APPLICATION FORM

NAME (First and Last) _______________________________

UCO (School ID number)______________________________

YEAR OF STUDY/PROGRAM________________________

EMAIL ADDRESS___________________________________

TELEPHONE NUMBER (Optional)_____________________

DATE _____________________________________________



                                 Terms and Conditions- see reverse



In order to become a member of MIMSA a student has to meet the following conditions:

1.     An interested party must be an enrolled and registered student of the Faculty of Medicine of
Masaryk University in Brno


2.     The membership fee for joining MIMSA is 500kč for the 1^st year, decreasing by 100kč for
each following year, and with it a member receives their MIMSA card with which they can take
advantage of the benefits of membership (discounts from our partners, MIMSA materials, and all
future offers for our members only!)


3.     A student must comply with the Rules and Regulations of Masaryk University Faculty of
Medicine.


4.     All personal details of the members are kept by the association and they are protected by
the confidentiality rules and regulations of the Czech law no. 597 art 458 § 3/ 115 318550.


5.     The board of MIMSA reserves the right to suspend any member that does not follow the rules
of the association and/or the University.


6.     Members have the right to attend all social meetings of MIMSA.


7.     All members have the obligation to vote in the student representative elections that are
held in the beginning of each academic year.


8.     All members borrowing materials from the archive of MIMSA are obliged to return them by the
assigned deadlines, stated by the department of issue.



☐   I have read and agree with the terms and conditions




Signature:  _______________________________________________