Odessa National Medical University

Odessa - Ukraine
Personal Details (as in passport) Surname Name Date of Birth Nationality Marital Status Passport No. Issuing Authority Name of Father Permanent Address
Single Married Divorced

Application Form

Fill the form in Capital Letters Only

Sex

Male

Female

Issue Date D Validity D

D D

M M

M M

Y Y

Y Y

Y Y

Y Y

Personal Details (for correspondence)

City State Phone with

Country & City Code

Pin Country

Mobile Last Qualifying Examination Name of Examination XII / MBBS University / Board

E-mail Year of Passing Total % of Marks

Course Applying for: UG Course: PG Course:

General Medicine Specialization Stomatology Pharmaceutics Preparatory Course

Ph.D. Course: Specialization I, hereby declare that the information given by me in this application form to the best of knowledge is true. I do hereby declare that I bear full responsibility to follow the Laws of Ukraine and of my Country. The University reserves the right to expel me at any stage of the course on charges of misconduct / irregularity or indiscipline. My aim to travel Odessa, Ukraine is solely for the studies in OSMU, Ukraine.

Date & Place of Submission

Applicants Full Name & Signature

Recommended by Sub. Representative

State / Country

Signature