INTERNATIONAL STUDENT APPLICATION FOR
UNDERGRADUATE COURSE
IN ACADEMIC YEAR 2009 – 2010
FACULTY OF MEDICINE AIRLANGGA UNIVERSITY
PERSONAL DETAILS
| Name | (as printed on your passport or birth certificate) |
| Date of birth | / / dd/mm/yyyy e.g 07/07/1987 |
| Gender | Female Male |
| Citizenship | |
| Passport Number | |
| Marital Status | Single marriage |
| Religion | Islam Kristen Katolik Hindu Budha Others |
CONTACT INFORMATION
Correspondence Address :
Post / Zip Code :
City :
Province / State :
Country :
e-mail :
Telephone :
Facsimile :
Mobile phone :
ACADEMIC QUALIFICATIONS
Secondary Education
Name of Secondary School :
City / Country :
From : To :
Date of Diploma / certificate :
Number of Diploma / certificate :
Examination
Subject Mark / Grade
1.
2.
3.
4.
5.
6.
High School
Education
Name of High School :
City / Country :
From : To :
Date of Diploma / certificate :
Number of Diploma / certificate :
Examination
Subject Mark / Grade
1.
2.
3.
4.
5.
6.
7.
University Education : Are you a former or current student of any other university ?
Additional Results : Please provide, if available
LANGUAGE PROFICIENCY
Date Taken Grade
IELTS
TOEFL 500
Paper Computer Internet
SCHOLARSHIP DETAILS (if applicable)
Have you received a scholarship ? No Yes
Name of scholarship provider :
Please attach official documentation from your funding organization, including duration of scholarship, expenses covered by scholarship (e.g. tuition fees, living cost) and details of any restrictions on study.
PARENT’S / GUARDIAN’S INFORMATION
Name of guardian :
Relationship with applicant :
Father’s name :
Mother’s name :
Father’s occupation :
Mother’s occupation :
Address :
Post / Zip Code :
City :
Province / State :
Country :
e-mail :
Telephone :
Facsimile :
Mobile phone :
OTHER INFORMATION
Have you been convicted of a criminal offence by a court of law in any country ? (if yes, please submit document)
Yes No
How did you learn about FMAU ? (you may tick more than one option)
Family / Relatives
Friends / former graduates of your school
Teachers / principals
Exhibition / seminar
Visit to your school by FMAU
Newspaper / Magazine advertisement
FMAU Website
Internet search engine
Why have you chosen FMAU ? (you may tick more than one option)
Good reputation
Widely recognized FMAU degree
Quality of education
Availability of undergraduate program
Teaching and research staff
Research standing and capabilities
Affordable tuition fees
Cost of living
Favorable exchange rate
Others
To which other universities will you be applying / have you applied ?
Airlangga University is my only choice
Others………………………..
APPLICATION FEE
A non refundable application fee of USD 50 is payable. Please select one of the following modes of payment
Credit Card (Visa and MasterCard only). Payment can be made acknowledgement page after you have submitted your application
Bank draft made payable to Airlangga University
