AmceTa-JaHBJieuue / Application fonn

Ha nonyqemi:e o6pa.30BaHI1JI B POCCHHCKOH <l>eAepau1rn 3a C'-1.eT 6!0.!l)KeTHl,IX

aCCHI1IOBaHHH q>eAepaJihHOI'O 610,!l)KeTa PoCCHHCKOH <l>eAepau1rn B npeAenax KBOTl,l
IIpaaHTeJIJ,CTBa PoccHHCKOH <l>eAepauHH /fur education in the Russian Federation at the
expense of the Federal fimds of the Russian Federation within the quota of the Governm:nt of the
Russian Federation
3anomœeTCJI netJ:aTHhIMH 6 y ~aMH Ha pyccxo~ HJIH aHrmt:HCKOM Jl3hIKC. IloJUI, OTMC'ICHHLie 3HWCOM «•», Ofül38TCJILHLI ,lUUI
3aJl0JilieHR• Ta be completed Ill black letters Ill Russian and/or English Ianguage Fields marked with «•» are obligatory for
filling

C1'pa11a, • KOTopoli no,!llleTc• aHKCTa-3aJlllJJeHHe* / Country v.here the application is

submitted* PerHCTPaUHOHHLIH HOMep• / Registration number•

Kottro, .D.CMOKpaTH'tfeclGUI pecny6.mnca COD-! 0319/23

3ano.1HRemCR npeOcmot11tme..-1t!U P<P6 3apy6e:NCHo'Ù cmpaHe l Filled in by repre.untative ofRussian 3anOlfHJl.emCR npcôcmat1ume11e.u P(J)tJ Japy6eXHoii cmpaHc / Fllled in by "pruentalive of Ruuian
Federation in/ort!lgn country Federat/on inforeign country

JIHHHR npH6Lrl'.HR (HcToqHHK noc-ryruJeHHR 3aJlllJJeHHR) / Line of arriva! (source of application form)

D npe~CTaBITTCJILCTBO Pocco'I'pymrn:qeCTBa
D ,[{1mnoMaTHtiCCKOe npe,nCTaBITTCm.CTBO PoccnHcKOH Cl>e.ll,cpal.lHH
D ÜJIHMTIH3,ll3 IIIK0JJ&HHK0B
D ÜJIHMJUla,!111 )lIDI a6,rrypHeHTOB MarHC1'paTyphl
D Kottxypc, rrpoB0.llHMF.IH o6paJOsaTem.HoH opraHHJaUHeH
D Apyroe
3anonH1H!mCR npeckmaeume.'le.11 P<Pt1 3apy6e:>K:Hoii cmpaHel Filled in by~pruentative o/Rus.!ian Federotion info~ign country

BH30B3'1 HH(pOpMaIOIJI* / Visa information*

BHsa TPe6ye-rc• / Visa is required

Mecro II0.rrycteHIDI BHJLI* / Place of visa receipt*

C1'paHa• / Country •
fopoll" / City•
KoHrO, .ŒeMOKpaTH'iCCKU pecuy6JUO(a

D BIDa He 1'pe6yCTc• / Visa is not required

B crryqae aam11uui: .a.eikreyromeH BH3bl, yK333.tL: / Ifyou bave a valid visa, you must specify:

));an nonyqeHHR / Date of issue Aan OK0HSaHHJ! J1eliCTBHR / Date of expiry Mecro noJI}"ICHH.fl BHJE,I / Place of visa receipt•
1 1

B cny11ae Ha.mri{rui: pa3pemeHID1 Ha speMeHHoe np0)l()fB3HHC, yKaJatL: / If you bave a temporary residence permit, you must specify :

)J;aTa nonyqeHHR / Date of issue )J;aTa oxoHqaHHJ! )leliCTBHR / Date of expiry CepHR, HOMep: / Visa number:
1 1

B cny'tlae HaJill1-{IUI sHna Ha ïKHtem.crao, yKaJan: / If you have a residence permit, you must specify:

)J;aTa nonyqeHHR / Date of issue )J;aTa 0KOHqaHHR )leHCTBH• / Date of expiry CepH•, H0Mep: / Visa number:
1 1

1. <l>aMHIDUI, JiaTHHCIG:ft.n-1 6yKBaMH (B C00TBeTCTBHH c nacnopro M)* / Family name, latin 2. l1Mll (HMeHa), JJaTHHCKHMH 6yKBaMH (B C00TBCTCTBHH cnacnopToM)* / Name (names),
letters (according ta the passport)• latin letters (according to the passport)•

MUT ABU GEDEON

3. Cl>aMHIDUI, KHpJIJUIHu:eH B pyccKoH TpaHc1qnm1.urn* / Family name, Cyrillic Russian 4. 11MR (HMOHa), KHpJU111HUCH 8 pyccKOli 1'p8HCKpHnUHH* / Name, Cyrillic Russian
tran scrip tio n• transcription*

MYTAEY lKE)J;EOH
'Jano 1HJ1 e.mCR np edcmat111me11t!\1 P<P 8 ,apy6e::HOi oÙ cmpaHe / Fi lied in by reprventative of Russ/an 3anonHRemCR npetkmat1ume11 t.11 P<P i, ,apy6eJICHOÙ cmpaH t I Fi/led in b.v ~preun talfve of Russ/an
Federatio n inforelgn cou111,y Federotion lnfortign coun11:v

5. 0rlfCCTB0 (CCJIH HM CCTCX), KH pHJl.ID1UeÎi B pyccKott TpaHCKp HnUHH (B C00TBCTCTBHH c 6.MecTO polll!leHH• (a cooTae-rCTBHH c nacnopTOM)* / Place ofbirth (according ta
oacnopTOM )* / Father ' s name (if the re is any), in Russian Cyrillic transcriptio n passpo rt)• (CTPaHa, ropoA) / (colllltry, city)
(according to the passport)•

MY51HT1! KINSHASA
\utvî /fJi t'mLlt npedan ot1ume.1 e.w Pr/Jt1 Jo p r6tt::,,awû cmpt111 r: / Fi/led in byrrp~en tati w of Russian
J Fct.11.:rruwn info rdgn country

7, fl a1a po;t<JJCHH• • / Date ofbirth ' 8. llon• / Sex •

{, JJ; 1U,-MC CfüJ - J' O/J J / ( day•mOn tb- yearJ MyllœKoll / Male D lKeuc1mll / Fcmale

2 l-f 1?- l 11? /j

9. t 'pa)K;1a11cTml • / Ci t tzcn~ hip *
10. Cr,rryc cooTC'ICCTRClllutKa, 6eJKe1ma Hmt Ka3aKa / Compatriot, rc fugcc or Cossack
E c. 111 Hl,l )IK!llh ."ll'Ch r p aït-JlUIIII IIOM IICCKOJlhK IIX rocyJWpC'lK, YKilih:IITC HC'C rocy;mpcnrn / lfyou hc1vc
m.my dt i7,1;nsh1ps. sp,.:d fy ull SI oGJliJJJ,aJO ocoÜl.lM cmrycoM coun:111.'\". Ilh!IIIIHKa / l' rn a compal1iut

1) J..:0 11 r o , 1tc :i.1 0KJHJT11t1ccKaH pccnyGmJKa

O 51 1111uu 6 i.:·J rpaJK1t..lHCTf1r1 (m.: nru1>1 1oi.:h rpa>tvlitllllltuM 111-1 u1urnru rocy;1ap cT.R<P / [ 1. Co oTCt1ccTnc m 11-1Ka°M 11 smmnoTCH JIH l.lJ, po; umnmccx n·o,moMrocy11apcrnc,
11poa..1rna1011u1c 1m 60 11poiKttsaimmc H 11CM H 06m.1Ju11011u1 c 11p1n11aKi1Mff 0611umCT1t >1:n,,Ka,
,.nn a pi.:rso n ,.,.1t fwut ci1izcnship (l <11n not u citizen of any statc )
HCTOJlllll , KYJlhty p11oro w1c11e;ufH, tp a/U-IUHfr Il OÔhlttaCB, a T:'\ 1\,-KC [IOTOM KH YIŒl.lllllhlX
111111 nu ·u p HMo ii Hnc xo/1Jfl1teii m11111H . / Co mpatriot is a p'crso n bo rn in the cmu1try or
livcd thcre bcforc \Vho has comrnon la nguagc, historical, cultural fcaturcs cither a
lh:sccnJan t uf th ose.: pcrsons.
2. CoOT C tf CCT HCll ll l-fK.tMl1 TUJCA((' upwmcH0T CH JIHHa H H X II0T0MKH, npm1,,1rna101101c :ID
ll(lC}lCJlaMH tcppHT0p1111 PoceH fiCKOfÎ <llCJlCP .! ttHH U 0Tl!0CSfllUICCJI , K3K npaImno, K
11a p o m1M , IICTOPll'ICCKH 11p0iKIIIHII0IIUIM m.1 TCp p1nop1111 Pocc niîcKoi-i ct>cJtepa1 u111 , a
t aiotcc c}le1mnw1-1c cno6om1MH Rhl6op o 11onhJy 1tyxon110H, eym,ryp110H H npanonoîî cuHJH
C Pucc uiicKO ÎÎ <I>cm.:pa1u1 c n muu.1 , \fbU puJtCTBC IIIIIIKJI 110 ll pSlMUÎI ROCXO /UHHCÎi JHIIIHII
pa11cc npO:.t(HH;uu1 11a Tcppwropuu PoccHHcKoH <l>c11cp a1tHH, JJ TOM '1HCJ1c: / Compat riot
is also a persan ancVor his/hcr dcsc cnt living ahroad who hclon gs to nations liv ing on
historical tcrritory o!'th c Russiun Fcllcration who mu<.lc a choice l'or religion , cullurc
and lcgislat ion of the Russian Fedcrat ion including:
- mIua, cocToHBUIHc e rp aiKJt<III CTBC CCCP uhrnu npo)KltRaJOHtHc e rocy/UlpcTRax.
RXOJUfRlllHX R cocrnH CCCP, nonyaIHR11me rpaiK/ta11ctRO 1THx rocy1mpctR HJU-1
crna11111c JUHlaMII G1.:1 rpaiKJJ;IIICT Ba ; / a pcrson who h.id the USSR nati onalit y ,uuVor
living in cmmlrics mcrnbcrs of l hc US..c;;R who go t cil izcnsh ip of one of I hcsc
countncs or bccamc a pcrson w1tho u1 c1t1zc nsl11 p,
BblXOJUlhI (:,M11rpai1Tb1) HJ Poce uikKoro ro cy11.apcnrn, PoccuiicKoii pcc11 y6.I 111K11,
P CcJX::P. CCCP H PoccHWcKoH <t>cncpauHH, HMcaumc coo Tse-rcrByI0Iuym
rpa>tvtallCKYkl 11p11Hi.1/l;IC:.KIIOCTh If l'.TaRI/IHC rpaifQtalf a:\1 11 IIIIO CTIHlll/10 1"0 rm.:y;tapc-rna
11J1H ;ml(aMH Oc:i rpalh'..'tallCTmt. / Emigrants of th l' Rw;;sian S-!atc/ R11ssian lkp uhlir /
RSFSR/ USSR/ the RlL<;sian Fcdcra t Ion who had a cit izcnship and a<lmi11ed to fo rcign
citizcnship or hcc;imc il persan wilhout ci t izcnship .

0 j{ 0Ci11iJJJ,aw ocofiuM crnrymM fü;,KCll!ta / l'm a n:fugcc

Q .si MBsu11oc1. noT0MK0M Ka3aKoR / l'm a d~ccndant ofthc Coss,1cks

1 1. Ai tpCc 11ocTow111mro 11po>h1-1Kamu1:* / Permanent addn:ss:•

11. I CTpa11a* / Count ry • . J 1.2 no•1TOBbt(1 HllllCKC / 11.3 Ofinacn. / lHrnT / Pcn1011* Region / Slatc / 11.4 ropon / Haecnc11111,1H 11ymcr• / City /
Postt.:o<k Location* Community*
Ku11ru. ;t...: :\!UKp a T IP I CCK.J)j
pcc11 yll1111 Ka O'lX KINSHASA KI NSHASA

11.5 Y.ru !ua ..10 ~1. Knpuyc. cTpoc1rnc . Knapn1pa• / Street, house. huilding, flat•

Av .Yas« 50 , Kimbasckc, Mukali

1 2. A ; 1pcc '}; !C l<"I p O HIIOÎi IIO'I T hl* / e-m ail * 13 . HoMcp Mo611m,11oro TCJ1c<j1 011a (c KO / lOM cTpa11h1)* / Mobile (ccll) phon e numbcr
(\\oth a country code)*
rcd'-·0111nut:1h1!frt•a)gma! l. com +243 X2S5 -,'17 X4

\ ,i . K n 1rraiç11,1 po;tHTC1K· i'1 HJ11 1 ·mK011 11o r o 11pe11cT a 1u1Tc JŒ, 11c Hn;u110111crocH po; lH TC-nCM* / Contacts of parents or lcgal rcprcscntat ive who is not a parent•

14 . 1 Ko1 1Tahï U pu JU!T(.;Jfcii:* / Pan,; nt s' i.:ontacl s: •

t '1 .2 Koi n aKn,1 •ia t:l i t iimr o 11 pcJ lCra tu n cm1, 11e MtUIM to1 111: r ocw powrrcJ1CM (H c11y 1 ia c uco6xo1u1Moc-r1-1):* /Co ntacts or \cgal rcprescntal ive who is not a parent ( if it is ncsscsary)*

(J );lMtl!l m ! * / Fam i ly na m e viMM * / Namc• O-ri 1c CTHO ( ccm, HMC:CTcM)* / Fathcr's naine (ifth c r c is any)*

:v1 USIT U ~1UYAN GI

J'pa i1'-° t;111i..:T11u " / Cit izc nsh ir• ){am poa;;tct111H* / Date of birth* (JlCHh-Mecsin- roJtl /(lby-month-ycar)

1%6-03-13
Ko11r o. Jt1:MoK pi.iT1t ~1i:c h'iu1 p1:c11yG1111Ka

 .1 ij1 CC l!ll°I\J p o 111 wii 110•1 n .1" / c-muil* iluMcp Mo611J1blllJrO TCJ1C<\lo 11 a.(c K0Jl0I\I eTpa11bl)* / Mobi le (ccll) phon e num bcr ( with a
countr y code) *

:( 1SUL· m a sas12 tj1 µ1 n.1i l.cum +243 8 13 25 1820

C! 1.1,111 . r1 111 .. i I·,1:n i ly n ,11 11,: " l1rn1• / Nain e• O-r•1ccTHO (ccm1 11f\l cc·11:11 )* / Fath1.:r's na me (ifthcrc is an y )*

Mufi ya

)"(aTa pmK.!tCH11H• / Da t e nfhir th• (JlC llh- Mcc ,m - ro1t) /(dn y-mo nth-y!.!a r)

196 6-03-IJ
K, 11 1. u, , ,,:·.. 1, r/1" c11 1 11.·Ck.';Hl' p cc 11yCim1Kn

HoM...:p MllG11m,11uro TcJh:t~o 1rn (c KoJloM crpa111,1)• / Mobi l1: (ç 1: \I ) ph u ni: nwn lx.:r (\vl!h ,1
1.: ount ry code)*

,.,• . ,! 1 , 11 :,: .:1 r u

J(> , !JfJ kt,U,J'! 1t• / f) J\i.: I '/ . )lc i1r 111111 i..: 11...: 11 mi• / Va!1LI t1ll* ( Jt1: 111,- Ml:C >l ll- l'OJl) / (<luy-111011 t h-ycar)
• I I H,°' :
ni 1-,· ..: "' L1u n, /\!l'l.. ~ fl
, 11 .· , ! (d,:) -n11 , ;HI ,· ;~· .1 J

) 1/ · ' 1
? O 111 711 "~
'1 l! I ' ( IH 1I, , l..:\I L l h l l): li. Il ll 11p 1,1 Ill' , h l!l,l,l ' ll Il l' 1 l'Kil ! 1, Jlill l l'l' , ' ICA I ' I V!' l° 1 1,_"I 1 11 ,' li l L ,1 li"l l h l ll i\'1 ,\. \.1 '\~• (I r 1 11:UI 1\1 1H,I (.1\ Ill Ili•, I \ Lt.lll. 1l·,l,I\ I.I
 oc11o e11b1c 0 6pa1o aaTeJ1h111,1c 11por p:tMM1>1) / The va lidit y of the pa~spo rt should nol expire carlicr than 1,5 yca rs from the da te of
çommcnccmcnt of visa va liùity (for long tcrm prub'Tams)
CpoK JlCÎiCTHHH uac11 oprn f!C } (OJl)f,.""(!JI HCTCKi.lTb pmrcc. •!CM 11e pc3 0,5 roJUI C )L<}T hl OKOll'latlHR JtCHCTHH II HH3hl (J.trlK flOCTym110111HX 11a
1<paTKocpo•1111.1 c o fipa:mRaTcm,111.Jc 11porpar-.1M1,1) / The validit y of the passporl should nol expire carlicr than 0.5 yca rs from the
cx n irv date of visa {for sho rt tcrrn no •rams\

1:-: . Yp0 Hc111, 1r0Hr 1c111 1oro (11r-.ic101w:rocsi) oôpalo na1111R • 1 Leve l of cdL1cation"' 19 . l lai 1Mc1 1on:11 11 1c 06p:11onaTcm,11oii opra11 111a1m11. KOTopy10 8 1.1 1.JKOJP111m 1, 111111
ofipaïnnaTcm,noiî opra111n1.11urn . H1<0Topoii 01,1 ·~attcpnracTc 06y•1c1111c* / N:imc ol'
B1 ,16cp1rrc Tû m,,-o n1u111 ttap 11 a1rr - 06pa•jotta1111c. ua 6il'.IC 1m1 oporo Hhl iK1..'JIUCTC y •1111 1,n1 g.raduntccl cducat mrrn l nru:m1 za1 inn nr t hc cduca11onal nrganîzal inn \,hcrc you an:
u r occ1111 / Choosc ONL Y one option - t hc cducat 10n on I hc hasis nf \\11tch you want to complet in g your st ur.lic s •
,i m!y in R:L..;si.i

0 Oc1H)HJ1o c \161ucc.· l> 6pa1otta1111c (u1K0Jm. JIIHll'Î1, n1M11a111w : 8-9 JICT 06 y•1c11 11~) / UN IVERSITE üE KI NSHASA
S.:i.:o ndary &.:h ulil (8-9 stuc.ly ycars)
20. Mccn, 11axm1.;;1c1rnc 06pa:JOua·rcm,11 ni,i opra11wm1rn11. 1<oropy10 131.1 1a K01J1111 m1, 111111
0 Cpc.·;'utcc onlucc ofîp :non:11111c (rnKO Jia, m111cH. n1M11aJ 1tH; 10-12 11cT 06y •1 c111u1) /
0Gpa1nH<1TCHh J10ii o pn1111 r .m1u111 , H KoTopoi1 B1.r ·mttcp111acTc 06 y•1 c1111c• / Locat io n of
r,\.:!ll'ra l s1,.•c o11<bry cducat 10n ( 10-1 ). si udy y cars) gra duat cd cducatio nal org:111iza1ion or the cduca t iona l organ izn tion \...tl crc you .ire
complet ing your studics •
O {·r c:u1cc 1rpo1 j1ccc11011:1m,11oc ollp ,11ona11uc (11potlJC.•cc11011nm,11 oc y •111m1mc.
Tl..' x11 ::Ky.,1, KO J!.'!<'.'ta-) ) / Srcnnr.ary v,icational cducat io n (Vncat1on.ilf l" cc hn ic;1I 20 . 1 CTp.111a / Country 7. 0.7. rop oll i Ci l y

Sc.Jrnnl 'Col lcgrs )

Ko11ro . JiC~IOK}laTIJ!ICCKa}I pcc11 y ôm1Ka KINSIIJ\SJ\
/iaKa:1ar1 p11<1T / l.hc hclor' s dcgrcc

O C11 l'11 11a.111 1TeT (m,icmcc 06pa1ona1111c co cpoKoM 06y'ic11 1-u1 5- 5.S JICT) / Spccialist 20,3 Ymma, 110M, 1mp11yc , npoe1111e / St reet, IHHL~c. building

dcgrcc(!l ighcr cducat ion 5-5.5 study ycars)

CAM PUSIUN IKIN
O MJ rncrp:rrypa / Mastcr's dcgrcc

O Ac111r.i:,a 11Typa / Postgraduatc srndics

2 l. ro1t OK01111 a1111 R / Ciraduation y ca r

0 Op.ru:11aTyp:1 / Rc sidc n1:y lra ining 202 1

Q ,\;n,1011..,-r yp.1 / Pus1gra Ju:i t 1.·. mi li1,1 ry co urs1.:

Q Âr U!L'Tl' IIT~' pa-cTait.--;1p o1JK:.t / Assistan tship-t ra inL·cshi p

U CJl)'' l: l >i X . y c·1a1 10 RJl\.~ 11 1Jh!X J.1KOIIOJI:1Te!lbCTBOM PocculicKoi-i ct>cncpaUH II , M 0)KC1

llüT p cÔo H:ln, i.:,i y1.--ra 110RJICIIIIC Upl nHJ /111){ n pcJICTii BJICIIHI.IX JlO l<YMCIITOB oG
06 pa1o n:111:11~. / J\c co rding to the lcgislat ion of th e RlL'-Sia n Fcdcration. it may be
n.:ljuirl.'d 1(1 ~:,,1 ;1blish {hc n:cugnit io n o f thc suhm il tcè cducat io n al i.:~rt ificati.:s.

, , Y p 11HC!!h n 6pwJORi:ll lfR . twTopoc IJJ.r xo TIITC 1to:ry •rnT1> R Po cc1111 * / Leve l of cducatiun that you wanl w gct in RtL~sia*

Rh1Ücp 1-11 c TOJ/1,KO o;m 11 t1ap~w.11 T / Ch oo:;c O NL Y one opt ion

O Acu upam yp;i / Postgraduatc Dcgrcc

O li:rn,u:ittp11a-r / Un<lcrgr~1<lua! c De grec

Man rcTpary pa / \1asrcr':, Dcgrcc

O C111..·1r11amrrcT / Spcc1:1!is1 Dcgrcc

O /\; ;1 , 1l 1i1K1ypa / .' \,iv,11. '.\1ilitary. an<l Othcr l'u st -\ ,r a<lu.a tc Sludics

O (.' p c:u rcc 1:pt1 rj1cccH0 11a.'11,11nc ,1l1 p a1ona11H C / Scco ncb ry Vo cational Ednc;1t io n
0 J\ \." ..: ,:\."TCII ry p a-c.:T a;+.""upotti<a (uo i.:11c1tHaJ1h110 \."111 H ofü1a CTH i<y m; r yp hl 11 11cKyCT Kll) / Assis1a111ship-l rn in ccship (spccialitics in 1hc field of cuit ure anc.l art)

O Op;u:JJ JTypa / Rcsi<lcm.:y

0 }ln11n :urnrc.'!hUOc 11pn,!1ccc110 11am:.11 n c o ôpa1o na1mc / Aclditio nal Vo cat innal Trninm g

11:rma rnic ; ipu r pa.\ 1, 11;1:to!IUJrll lfTCJtL II Uro upoqJc\."c11o11; 1m,11 ur u 0 0 p11:so n.11111R (!ll IO) / Namc uf thc Suppk-mcntary vocutiu nal !.!duc;.1tiun pro grnm:

Jl po;10 :1n,::n .·111,Ho1.11, 0Gy•ri.: 11 Wi / Dura t io n ofst udy :

_ _ _ _ __ __ Mccu1 1\." n / rn on t h~

Cc Ml.'C l p / rc n11 ·

O lkc ,.:11 1111ii i.:t·M~c."1 p / Sp rin g ~i.:m estc r

l~ .'k1w1w lllli< U;1 / S11m m cr sdw ol

1- -'iil· ,~ 111.1lr r n ,1 .1 At ;1dcm 1c yl·:11

T

0 < J..1,.'l! lftt ii u ·r-1(-crp / Fall ~l·rn c :\ 11.:r

Q h 11 ..ff J!IIUL!J, \.\ 1!l l1,.' I' ~rlwu l

1~- () '"·"·' ' .dl Ili "

0 O•r 1w - ·,.io•1 11;1>1 / l':irt •l im i. : 0 :.h10 1111a>1 / Extrannu, d

, (L ' ! ·11111 •·1 tru l 11 W I) •111 i ~ f ll L 111rn 111,1 uu; 11., 11p1irjll·L·c 11>1 ) (lit' 1a 111 1w rnL··r cH 1\ c l)' 'l ill' 111,1(iop n l )ÔY ' l \." II II R 11 0 l l fllll (HlMMilM Jll 10)* i bh1l'a t ion al IH '\l~r.uu
1
1 J! !, '1 i :l',/ , I. ). l,:.~,,~ i ::1 ·; ! \ ' , l(.rll I U\1;1 ! ;lh. .l :11
li ',111[ d 10 11M: 1o ·,! udy ,U \ lie S...1p p k 111 cnl al }' \ lll'i11 1on: d \.'lhl\."a l 10 11 r· , . .
1 ' ' , I l , 1:•. , p 111 i. ::,, 110111-· 11f u1t· rr11 ,1 •11 , 11o c 11 11 11 c 11011 ,.1y it 1\." L, iil 1 ll L,st a -1.: du .111 / Y1 11 1i.:,111 UM,.' l ll!->S lll- l' \lu Ill W\; b~III.' 111 tm d \Ill' 1.'.1Hk and t hr tull 11t111H.' o l
I . • I' ,1, , !1. 1 !t , :•. :(ll l li Il ll !p ' 11 \ .J ,1 ,I Li ,l ~I
1 1
Lll ,1 !r ":

:1 ,1 ."' l l:i 11~1t· 1H1 t1d 1H1l· "" / Full 11 11111 L·•
 1 1·11 1m o McTco n o 11or 11 jl
11 , .0.1.(14
25. T cM :J lfCCJIL'J.lOH:.1 111\ÏI ( .!l1[,ll IIUCT}' IIUIUUUIX IIU 06r1c1111c 110 11po rpï:1M MilM ac1111p.urryp1,1, acc11CTCtrryphl-CTa,+,.11poHKII, opJUIIIUTyp1,1) / T opic of rcscurch (l'or postr1aJualc SI u<lics,
,1ss1sta nl i.h1p-tramccsh îp . rc-sitk nc y lraininu)

26 O(ipnniw.TcHLIILIC opra11111..1u1111 (y1111Rcpc11Tcn.1, 1<om1cJCA01), r;1c 81,1 x0Tcm1 ÔI.J y1rnn.cjl• / Educational organizations (wlivcrsitics, collcgcs) whcrc you would likc to st udy•
1ai10m11 rn: KCl' (1 l"q)Ot. H IIU(J MJI I.C llflHOJlH TCTll. 1lc Hht Ôllp:ulrc 6o;11,111 c 3 06pa10H arcJlhllhlX opra111nar111ii Ill O}lllOrD ct,c;1cpam,11oro oi,:pyra \{ IIC 6om,mc 2 o6pa30li<t1'C.llhlfhlX opr;1111naw1ii r . MoCKfU,1, r .
1
0 CJ IY'HIC. cc.mi Bi.1 yi.: U"JaJUI TOJll, l<o u : u1y u6p1notta1·CJ11,11yt0 oprJllll'Jill!JIIO, H Ollil llac IIC' RMGpUJIU Ili\ o6yitcmtC', Bhl JUUll..!CTC'Ch BO'J MOif<IIOCnl 06y 1c1111H a Pocciriic1wii
C;111i-1 - \h.•1c p\i ypra II r . CctHIC'lUIIOJlh.
Fd ! 111 :tll (1 r111ÎUl!'l hy priu rily. Do not tfoinsc more !han i.:ducati1111ul org:uul'...itio us Gum nni.: ofî:<lcr.i\ n.-gion untl 1111 more than 2 ctlucational organihitions from Mnso1w, Saint-Pclcn:hurg and
tl1ci1...:pJt1lllt /
St·V,\.'hlfml lf ynu m cnti1m on ly one cduc.uional 11rgani;.-;l\10n and this organi n 1tion rc!i.iscd to ndmi l you. yo u will be finnlly rcfil scd tù study in 1hc Russi.111 Fcckralion.

\) C:i11 i..1-ricr cpfiy prna1il rocy11a pcrnc 11111.1ii y111rncpc1ncT / Saint-Pct crshurp Un iversity

:':J Po1:c iiiici,:11îi 1·ncy •mpcTK1.:1111M ii a.-pup111,1iî y1111ttcp c111 cr MCXA 11.\lç 1111 K.A. T11M1ip~nL·na / RlL"sian Sla\c Avrnrian Un1vçrsity - Mo sçowTim1ryazcv Apricuilural i\c:1dcmy

3) 1":;nam: 1rnït (llp11110 J1if<cK11fi) (hcnc p:U tb llh!ÎÎ y11 n11 c pC11TCT / Kazan (Volpa l'L' )'ion) fc dcral Uni vl·rslly

,1 ) 1kpMCK Jlii ro cv11apcrnc11111,1ii llélljllOlli\Jlhll!.lii JIC(;Jl..:flOBaTCJll,CKlliî y111mcpC11TÇT / Per m Stat c University

o6pa30RaTCJll,llhlX opraiunan1-1H , IIC

B c .11y•rnc C C~III '. UJSIR li'a IIC fit.1:1a OTUiÏIJ.llla olipaloKaTCJll,HI.IMII opramuaumfl\111, )'Kil]«llllll, IMH B anK'CTC, JtOChC JIOR0/1.IITC."SI JlO CRCJlCIIJ.1R JlRYX
y i,:aJ;\Jllll ,IX 11 :tll KCTL', 0Gy•1a1011u1xc}I 110 OCIIOAlll,IM npo4'ccc1101rnm,111,1M oôpa:mn,rrc;n,111,IM
nG Jta Jlél hJIIUI X IHIIIMClll, IIIIIM Y! lC!ll,llh[M RCCOM IIIIUCTpa11H1,IX r p:t,K,l{all B 0G111ciî 1 111CilC IIII UCTII
:1p o1 ·p a ~IM ,IM 1:pem1 11n.·x oGpalOHi\TCJJl,111,IX O piï111113<UUti1. pl'amnytOlllltX 06pa1011aTC'JlhllYIO 11porpaMMY cpc1u1cro 11po1j1ccCHOl!l1JlhllOl"O 06paJ OKa1111H. 111,ICIIICl'O 06p,11011a 111-1SJ HJIJt

110 110 muiTc;11,11 yin 11po1j1cci.::11011am,11ym nporpa~iM Y, 11a ofiy•1c11uc no KOTopoiî 11pcrc11Jtycr Kil llJUIJtaT. / lfthl· cducatinnnl organizi.1tions indicated in the application form did uot
iH'l' Cl>I yo u for s tudy, ·y uur application wiU hi: sent tu two uthcr educ11tio1111I org;mizations that have the smal\cst proportion uf forcirJ1 citi zcns among all cducatiuna! urganization s

accurd111g to the choscn progr;u n .

:. ·1. lt m:1c1111,_• )n1.1i,;a~111 (11KJno•1aH po m1oiî >i1L1K) • / Lan guagcs (including native)•

1 ·1 Prcc1rnii / Russian Pom1oii flm111r.!10 rno6o;um / lî l!TafO CO CJIO KapCM / ! le tulaHC 10 /

D
,rn,1K / tr ,à a10.1111111y. roHop10 /
D Native D Flue nt D ln tcrmcdiat c Bcginncr Do not spcak

2) Fren ch 41-t'f:HO CO CJlORapcM / Ile RJ!aJlCtO /

D
t~ ~11u1y :.1cK11i1 / roeop10 /
Bim.1 1ct0 ct106011110 I
D
4Hrn10, m1111y.
D
Pom10H stJhlK /

Nntivc D Fluent lntcrm cdia tc 1-lcginncr Do not spcak

28 . l lcu fi x.o;ui~wcTb 06y 11c1rn i. 11a 11011roT01mn- J1h1t0~1 OTJtCJICIIHH (1(1aKy11bTCTc) / Ncccssi ty to study at the Prcparalory course (Prcparatory dcpartmcnt)
}! IIYA\.' IJ IOCh Il o6yitr.!IUH! 11a IIO)U· oTORHTC'flbllOM OT}ICJ1Clutl1 ( r!KtK)' JlhTCTC) /LIU!. H1Y4CIU1lt p y ccKoro liJhlK"J . CpOK 06y•1cmu1 - l ro11

B ·ni l\r L!~"!; ]l' pa1:1l pl:Jt(;JIC IIII K;111; u 1.1.a TOR 11 a u Gy11c 11111.: l!;I 110,I U"O TORIITCJlh\lUM OTJ(CJIClll!lf (ljlaKyHJ.TL."TC) ocymc1:TRJllil"TClt M111111crcpçTROM 11ayK1t Il 81,ICIIICl'O oGp,noR.11111.JI P occHi11:KOi-i

ll11.:::1.·p a11:111.

1 nccd t,1 gel admi~sion lu thc Prcparatory course (P rcparatory Jcpartmcn t) fur the stuJy of Rwsia n hm1..,•1mgc. Pcriot.l of st uJy - 1 ycar. ln that ca se cducatio m, l orgm1izatiun is to hc
chosi."n by 1hc Mi nistry of Sc ience and llighcr Education of the Russian Fc<lcrnt io n

30 . /IOIIOJII IIITCfü,llillt 11mJmpMa11m1 () /lOCTll».'Cll!IRX R

paJHhl X 06; 1;.1 CT HX / Addition.i l inform;!lion abo ut dillL·rL'III
29. C11oplïl fUli,II.' .10Lî:i-.Kc1rnw / Sport ;u.:hicvcmcnts
achicvcmi..-nts

31. T 1m u T Ôo pu 1 111 w x lfCJll,ITillllliî. IWTOp l.lC 131>1 11po xo;u11111 B l:tm cii npa11c /UHI 32. MccTo 11po xo"'11.C H1U1 0T6opo•111b1x 11c111,rrn1111ii• / The place of l{ll;\liti1:at ion
11 0 .11y'l c111isi 1<Ron.1• / The type of qu:i lilicat ion tests t ha1 you ha ve takcn in yo ur lCSIS p assing•
c.:ountf) 10 gct !hl.' q uota •
O np cJtcrneHTCHLCTBO Pocc0Tpym111'1CcTBa / Reprcscnrnt ivc office of
O T cc1 1!po ffiU1l!C I Tcs1 Rossotrudnichcst vo

O Knm,ypc .1ncyM c11 r n 11 n6 oôpa·1oeam111 11 (111m) i,;11amHjH 11<amrn / Edllcational Q t lmrnnMaTH•tcci-:oc 11pcJtCTaHnTCJ1hCT HO Poccultci,.::oii d,c11cp,uu1H / Diplomatie

Ccn ilk.itc Compc1i1ion rcprcscntativc of th e R1L-.sian f-c<lcrul io n

(J r1u1p•1ccKn c Hc111.rrn111tc / Crca1i vi t y test 0 0 6 p a :me,1rc11b11alt: opra111rn11 tHR / E<lucational orgunization

0 K111111.1·pc w,pnt,om10 / Po rt fu liu Cu mp ct il ion O Jlpy roc (yic.13.111,) / Othcr (spccify) _ _ _ __

Q Cofi1:cc:lnn;i 1111c / Int er vi ew . J3 TOM '111 CHC , C IICIIO Jl l>'.lCH¼II III CM JU ICTa lll{IIOllllhlX TCXIIOJIOlïlÎt C

II JlCIITllqlllKiLIUldi JIH 'illUCl'll npu llpOXUji\,I\CIHIM Mepo11p11KTl\ li (yKa:s1.macTCli

Q Ü J!HMrnrn 11a / Aca<lcm1c Compclllion
ll}UIUHJ)CMCllllO (; MCl:TOM llllO RCH.C IIIIJI oTGopo•tllt,IX 111:111,rram1ii)• /Usi ng tlistalll.:I.'
0 )lp yroi1 (ytGna1ï,) / Othcr (~p1.:1:ify ) _ __ _ _ tcchnul ogics with persomdily i<li..-milïcalion durin g the 11.:st passin g (the plal"I.' ur
4.ualiticalion lcsts 1rnssing an <l this s1.:ction ale in<lil.'atc<l al the samc timc)•

31 K 1:1 HwK·1 1:-1101 1p 1-1:1a1a10Tc H ci1c.r1y 1otw1c ,110 Kyt.tc.· 1n 1,1: / I atl ach th e fo llo wi ngdocumcnts•

\. K 11;1 :B1 :1 ~cunp1a " / Cù p y oft hi.: Passpon•

). 1~11:1 11 ~ :t•IKYMl' l n a o(i {lf) p ;noH:tlll11i (1! H11 .' IOK)' MC ll'l , L'. OJ(Cp ;+C;.111ll1H CIICJlC: lt\tH 0
O 8. Krn111J1 HO KYMCHTit 1: pc·JyJJt,T<lTUMH 11p o xoït(J1c1111J1 06J1 'WTCJ11,11 1.1x 11pcmrn p11Tc111,111.1x
o np cnc11c11111,1M
MW U11ll111C KIIX OCMOTJ>OH (11 p 11 IIU CTY UJICIIIIII ll ll OÛY'll.:IIIIC JIU
pi.:1y m .1,r1,1x \1( 11..:Jl(;JU! ('Ïl ai-iccnu11111 nocJJC}U ICl' O r o Jl,i.1 0Gy •1 c1111H, CL'Jll t u G)"ICIIIIC ClllC IIC
c11c1urnm,11ocT S1M) / Copy uf t h e ducwncnt with thl.' rcsults of p:issin g prd im in:1ry mc<lical
WtCp!m: 11 0)• / Cnpy of t he LduL' aliunal Ccrti lÏ 1:a1c ( l l r a Jocum cnl 1:ontainin g in forr11;1tion
cxaminutions (whcn .ipplyin g for lrain ing in so mc cJucatiun al prugrums}
,1hout 1ne rc -.u!t !, u f l h1: l;.ist l'C rl lfi c ;1! ion uf 1li e las! y ca r of st 11dy, if t hc st ullics has not
finish cd y i:t J• O
<J. P c t\1cpuT 11u Jl}'L'CJ<OM 11 /111111 a11rm1iî 1.: KoM S1'J1,1Kc (JUUI 1w1:Ty1ia101101x na 1JGy4c1111c 110
11pul'paM .,t:1M ac1mpn11Typ1,1, accHcrc11Typ 1,1-cTmtmpoKK11, opm1mn-ypt.1) / Rcsc.uch p;1pt'r in
Q J .c·111 11c 1i.: .o,c nu1 o 1q111 .111a1rn 111 11HJ cT pa11 11111ï1 0Gp1no11a1111 11 11 (11 m1) 111 wcTpa1111oii
llussian atuVor English (for pos1gradua1c s1udi1.:s, assis1an1shi p-tr;tin1.•eship. rcsidcncy
1m:i:11u:11ma 11111! ( !l fll! 11;1 : m• 11111) / Ce rt ificat c of ri.:L'ognit ion nf fo rci f~n cducut ion un d (or)
t raini ncl
f-, rc!gn q..ia!t ik .11 tons (1 !' :1 ny)
Q ,';, Kn n: 01 MC.1llltll!!C lmi , 1.:1 1p [mK 11 , 110: rr11q1;4v m10111di 0 1~·y 1c 11,11 c MCJU t l\lllll' Kl 1X
O \ Il . ( 1111i.: 01< 11y01111K:111111! (;uui 11 0c I y 11 :11011111 x 11a 1.>0y 1 h.·11111: 1111 11 pn 1 pa .\ l,ta.\1
HCl1L1pa111 yp 1,1, UL'CliCTC J1T yp1,1 - CT:nK11p1iHKH, OPJUf llaT)'pht) / (.ist o f pub\i1:al IOll S lfor
upll 1~rnr 11 :11 K:n ;: 1111i1 }LJII 110y •11: 11 1111 • / Copy of t Ill' 111 cd1ca l CL'rl 1fiL·atc i.:o n1inni ng th l'
post graduat c st udi~s. assis\ ant sh ip- l rainc csh ip, rcsi dcncy t mi n ing)
.i h~u 1c~ 1)1 111cd1c al con tr:iindic.1I11111 .-. fu r t rn111 1n tc:•
J. Ku!!it!i! Ml'.lH II Lll tctwii rn p:rnut o(i o1cy 1 c 11u rn HMli II Cl IMJl • / Copy of the m cdic al 11. Cornac He K.tll }U1.'t:rra 11a o Gpa GcrrKy 11 c p co11aJ11,11 1,1 x Jt:11 1111,IX •t Cu ns1.·n 1 ot' thl'
~. -;: IL,,: l' 011 1Ji i: Jb:..:ncc of' 1hç J !I V an<l Al f )S • Cun did.ttc lo Pi.:rsuna l Dat,1 Pro..:cs~ing•
111
'_J f, J.'11 1/llli i.:i.:}lllf:l ll H. l(Oi l CI tp i!H l01 o(Î U 1..: y l C 1111 11 1 k l'C X I II IIO R l l.'I111"1II1 U 11 1yri c1rnyrn; i., •
O 12. Ko 1111 11 HOKY MCIIToB, 11u;nn1.:pitvUJ to1iu1 x CTUl)'l: i.:0 0 11.!\\1,:l.'TRl.'1111111.:a / Cu pi..:~ uf

doc:umcr\l !'I wh ich co ntirm th e com pat rio t st ntu"

( , p• r l I t c ., ·,ut ;tl iTr t dirn1 c nn t hc nb..,~· nn: ,d .:d! t yp..:s 1) f hqla l 11 is :.i nd ll!hcrcu lnsi:-•
l_j '/
1

V ,: 1:n-• p i.: 1> 11 ,1,,11o11 , 11(1!!p11•111 1,1x Mi.:pn ll p llMJllil , a ·r akït.:C 11111 ,I\' JIOk1' MC: l!Tl ,l,
O 13. M11 1.1c ;1.n 1<y Mc11T1>1. 111),•n u,· r .ro1n 10 11m c 110 11y•1c 1111 c p..:1yHi.1a 1oa u11:m11.1 1.•lvam,111.1:-.
,1101: 111 m\:1111i1
(1m yc,-.io I p 1.· 111110) / 01 hcr d11 c 111nc n l s C\1Jl 1Ï rn1 111 1! l \i1.: ~•1.·t t 11,l' o l' th..: 11.::-.ulh ù!
1:, 1. , ,L p t , ;c,"; 11'· )' h ,, Lli Ill.il' ;i~· !) .-rt. 1.111.r { 1qn1 l ll'(lfl~ ll }lL I MO L' 111) / Cupy ûr I hc d1l(;Ul1\C ll l
111di vuhml ud1icv1.:11t cnt s (a l 1hr d1:-.l't'c li1111)
.'. ,
11 1
h •, 1, ( i hi.: 1 1.d n v 11 1!' 1 t ,1 ..
1
:1 11J nt hu d 11n1mc11t s n 111t 1rn11ne tlw .;;c rL';.;11h s ( 1f
, li' KY ~1c11 i 1.1, yK,n:111 111-,1c R 11 y 11 KT.1x 1-2 11 4-6. 11 pc,'IOCT!11tJUUOTC R c l.\Rcpcn111i1M IICfH.'BOJlOM ua pyccKHJi si1t.1K• / Documents 1-2 nnd 4-6 nrc providcd \vil h a ccrtificcl I ranslation in !o
RUS!> Ï:111•

:"1 . Jlo 11nm11ncm.11a11 1rnqmp~rn11m1 (ccnu xonrrc 'ITn •T O confü iu!Tt. o cc6c Jto11omnncJ1h110) / Addit ional informut ion (if you ,v.rnt 10 info rm somct hing alxrnt yourscll)

~5 . ll m1111,t 11oc11c 0K01Prn111111 06 r 1c1rn11 (11pc1u1om1rn cMOC MCCTO pa6on.t/1li1m,11cil111cH y•1c6i.1 ) / Plans aftcr grnduation (the prospective placç ofwork / forlhcr educc11ion)

51 / 1,.110 corm1c11c IIU 11pouCJll'lll!C o6pa6oTKM, lt TOM <[J-ICJIC e IIOMOllU,10 cpCJICT tt attTOMilTHlillllHt , MOHX 11cpco11am,t11,IX }Gllllll,IX, YK<l'.J(l/1/1 1,[X B /lllCTOIIIUCfi illlKCTc-·'-.111 1lJICIIHlf H upH Jllll"U CMl,IX

K IICM)' .'lO KYMCJITax , H UCJIII X pC11 Jllt 3t1 HMlt MûC ro ll!HlKa 11a llO JIY'I CHIIC' o6p:11llllilltllll li Poec11itcKCH1 (JlCHCj)ill lliU 3a f._:II CT 6tOJ1iKCT llhlX acc,1r11om11111H 1jJCHCpa.·1t.11oro 6.0Jvf<CTU. Jl ) [illO
COl . !i\C ll C 11;1 Tpil l!CI pa1i:t•111y 10 11 c p c.rt.1•1y MO UX 11 cp coftilJ ll,lll,I.X Jt:Utllt.l X , yKaJa/lH hl X H IHICTOIIIHCH IIIIKCTC-léH( tlJ ICJUH1 H 11pH Jla l"ilCMMX K II CM Y / lOKy M CIITilX, C HCIIO J/hJOHalUfC~I ecn1
tlmcp , 11: 1. 1 1 a\'. ccpt the proc\.'ssmg in ha rdware of pc:rsn nal ct.11 ,1 pro vidcd in the npplication and documen ts anachcd for 1hc purposc of rcalizing my rî ght ta obtain cducalion in 1h c
Ru.o;si;m Ft·lkrnt mn by budgct.iry ar prnpria1 io11s of fe-dcrnl budget. 1 agrL'C wi1h t ransbordcr trnnsmitt ing of my pcrwnal dma notcd in the 11pplica1 ion 11nd attacltL'd documents via
lntcrnc1 .

51 [[(l}IT"HCp ;+,:Jl.<110 JlOCTOHC plH) CTh 11pC}lO l'TaHJl)[CMI.IX Mlf(llO JtallllhlX 11 IIU/t)IIIIIHOCTI, 11pc11c1·atlJICllllhlX JlOK}'MCIITOH. / I conlirm the aecuracy of the <.lala I pro vi de ,ind the authcnt ic ity of t hc
s.ubm ittcd docw11t:nts.

ct>c;tcp:1111111 ]él cuoUll(CUIIC JIUil<lll,JX JIJIII /ICIIU Jl/11,IX CBC! lC llllii H a11KCIC IIJIII
}I 11po1 1111ji11p11,111pu1m11(a) 06 OTKCTCTHCIIIIU C1l1 H CUUTHCTCT!tl!Jf C :mKOIIO!UJTCJll,CTKOM Po cc 11iicKOÎ1

npCJtC\CTa tuK'1U1c 1m;u1cJ11>11Mx JlOKyr-.ic11ToK / I have bccn informcd of my rcsponsibility w1dcr t hc lcgislal ion or I hc Russian Fcdcrat ion for rcporting fa Ise or incom plctc info rma! ion in
th e ap pl icat ion for m or pro viding forgcù do cum ents

Jlaia • , Date• og Ma.A .:l_o ;t__ 3 llomrnct. • / Sign,1t ure•

(.ri..:111.- :\11.,:a1H·11.'l l 1 (day-month-ycarl

.,6 . }Iu ,1111,rc i1pcncn1R1 1Tcm1. 11p0Hcp111uucro 110 ; 11w·1y II JlOCTO KCp1tucn JU1t1110Ü a1tKCTht-'.llUIKJ1Ct11111 / Informai ion ahoul the rcprcscntat ive who vcrilic<l the complctcncss anù rclia hilit y ur
li11s :ipp hc:ition fonn
]u110.1/IH('l//('I( IIJll'/)1 IIIUH/11/11~1 , ~11 /'<Ji« 1upyii,•.'-f.·1tori ("11/flUIW Fi/1,•tl in lly f'l'Jlll'.t('r,/ul i l'(' " r R 11s.da 11 ,..-,·d('ru/i,JII in fon •ig11 , ·,J111t11y

Jlorr,K1H1 n1. c0Tpy.ru111h.u / Offit.:cr's Position 1 <!>JMllllliA H,rn ÜP<ccrnu / Full namc / Ku1<Ta«r11uii 110.icp I Contact numbcr

J laTa / Dat,c nu1umcb / Signature

(,rw11L- \!ti:i; !H ·,1.1 1 / {ll:.1y-m •1 n1h-ycarJ