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International Class of Medical Program

Applications

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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

Last Updated ( Thursday, 28 May 2009 18:35 )