Please, fill in the enclosed questionnaire

Q UESTI O NNAI RE

1. Surname, names __Mujahid T Ali___________________________________

2. Citizenship / nationality ________USA_______________________
3. Date of birth (year, month, date) _____12/17/1960_________________ Sex _____male___
4. Passport № _______048275470________________________
5. Place of birth _______Rawalpindi_____________________________________________
6. Place of stay (present address) ______5250 las Verdes Cir # 316, Delray Beach, FL-33484__
Phone:__1-904-361-9877___ Fax:_____________________e-mail:__emaengineers@gmail.com
7. Family status _______Single________________
8. Knowledge of foreign languages__English, Turkish, Urdu___________________
9. Health status ____________Fully Healthy________
10. Structure of family (total _6_ brothers _2_____ sisters_3_____)

father’s name ____Sardar Ali (dead)______________________, year of birth __1934_________

mother’s name _Khurshid begum (dead)____________________, year of birth ___1937________

11. Place of residing of the parents (full postal address, telephone, fax, e-mail), if differs from
abovementioned _________Parents have died_______________________________
______________________________________________________________________________
12. Country where you wish to obtain visa: ________USA__________________________
13. I ask you to admit me (please, underline):
- only to the Preparatory Faculty;

- to the Preparatory Faculty with further training at the General Medical (Dental,
Pharmaceutical) Faculty with the purpose of getting the higher education;
- to the Russian Language Course and for Post-graduate studies in speciality
_________________________________________________________________________
-XX to the 1st year of studies at the General Medical (Dental, Pharmaceutical) Faculty with
the purpose of getting the higher education with English as medium of instruction;
- to the Post-graduate studies in speciality _____Medicine or Dentistry___________
14. The work you did since completion of the high school (Advanced level) ___________________
__Got, B.S, M.S and a Ph.d from USA_________________________
_____________________________________________________________________________

Signature __ _____________ Dated__04/15/2016____________