mhr_admission_form

Master in Health Research
ADMISSION FORM
SESSION 2012-13

Serial No.________
Note: Please read the instructions given in the admission policy in the prospectus and at the back of this application form before filling this form:
1. PERSONAL DATA
Name:
Father’s / Husband’s Name:
Date of birth (dd/mm/yy):___________________________Gender: M

F

Married

Unmarried

Place of birth:_______________________ Domicile:_____________________Nationality__________________________________
Mailing Address______________________________________________________________________________________________
____________________________________________________________________________________________________________
Phone: (Res)_____________________ Cell:_______________________Email:____________________________________________
Permanent Address:
____________________________________________________________________________________________________________
In case of emergency, please contact:
Name:____________________________________Address:__________________________________________________________
________________________________ Phone:____________________Cell:_____________________________________________

ACADEMIC QUALIFICATIONS:
Name of Institutions

City, Country

Dates Received

Degree
Received

Marks Obtained

Total Marks

%

For office Use only
Remarks / Requirements

Receipt No. ___________________

Dated: _________________________

Checked by Member of Scrutiny Committee:
Chairman Scrutiny Committee:
1

2. LANGUAGE PROFICIENCY (For Foreign Candidates)

1. IELTS
2. TOEFL

Score : ________________________________________________
Date : _________________________________________________

3.

COMPUTER PROFICIENCY

( √ or X )

Email & Internet
Microsoft Word
Microsoft Powerpoint
Microsoft Excel
SPSS
Epi-Info

4. PROFESSIONAL EXPERIENCE:
Name of Institutions

Major Responsibilities

Position

Dates Employed

2