APPLICATION FORM FOR INTERNATIONAL STUDENT

Read this form carefully. Complete all sections with BLOCK LETTERS and typed.
Handwritten will not be accepted.

PERSONAL IDENTITY

Full Name : Mona Ali Mohamed elsayh

Distinction of Sex : famale

Nationality : Egyptian

Place and Date of Birth : Damietta 5/9/1995

Passport Number : A24999421

Passport Expiration : (DD/MM/YYYY) 7/13/2026

Home Address : new Damietta –Damietta

Present Address : new Damietta –behind elkafoury street

Phone Number : +0201018394435

Fax Number : Click or tap here to enter text.

E-mail : dr_monaelsayh658@yahoo.com

Previous University/Inst. : modern university for technology and information

 BACKGROUND
(*)high school for undergraduate applicant and undergraduate for Master’s program applicant

Academic Qualification(*) : 1. modern university for technology and information

2. Damietta experimental language school

3. Click or tap here to enter text.

Qualification Name(*) : 1. bachelor of pharmacy

2. high school diploma

3. Click or tap here to enter text.

Qualification Type : 1. graduate (bachelor degree)

2. pre graduate

3. Click or tap here to enter text.

Specialisation/Field of Study : 1. pharmacy and pharmaceutical products

2. Click or tap here to enter text.

Work Experience : 1. care pharmacies (18/3 till now)

2. seif pharmacies (1/7/2019-20/2/2020)

3. dawaey pharmacies( 12/8/2018-30/3/2019)

Social/Community Involvement : 1. resala charity

2. Alashanek Ya Balady association

3. Click or tap here to enter text.

 STUDY PLANNING (Faculty Applied for)

Study Program : Biotechnology

Period of Study : 2 years

Starting of Study : jan-20201

Program ; *please check (✓) in appropriate box”

☐ Bachelor/S1 ☒ Master/s2 ☐ Non-degree

LANGUAGE PROFICIENCY

1. ☐ I am from an English speaking country.

2. ☒ My previous study was English.

English Proficiency Score :

TOEFL : Click or tap here to enter text.

TOEIC : Click or tap here to enter text.

IELTS : 7.0

etc : Click or tap here to enter text.

Other Foreign Languages :

Language Spoken Written

French beginner beginner

 ADDITIONAL INFORMATION

*circle one of your answer

Have you ever visited, studied or lived in Indonesia? (Yes/No) *if yes, please specify

No

Have you ever studied Bahasa Indonesia? (Yes/No)

Would you like to study Bahasa Indonesia during your study in UTS? (Yes/No)

Would you like to help promote UTS through writing, picture, and video on social media? (Yes/No)

Do you have any relatives/family currently living in Indonesia? (Yes/No) *if yes, please specify

Click or tap here to enter text.

Please specify any special circumstances that need attention (e.g. disability or medical attention).

Click or tap here to enter text.

APPLICANT’S STATEMENT

*please check (✓) in the box”

☒ I certify that all the information provided on this application is true and accurate.

☒ I agree to support UTS by submitting a written, picture and video testimonial at the end of
my study.
 Applicant’s Signature Date

8/18/2020

Mona Ali Mohamed elsayh

(Applicant’s Full Name)
 DOCUMENT CHECKLIST

Name of Applicant : Mona Ali Mohamed Elsayh

Country : Egypt
Desired Program : biotechnology

☐ Bachelor/S1 ☒ Master/s2 ☐ Non-degree

*please check (✓) in appropriate box”

No. Type of Document Submission Status

Yes No

1 Application Form ☒ ☐

2 Motivation Letter ☒ ☐

3 Copy of Bank statement(**) ☐ ☐

4 Personal Statement ☒ ☐

5 English translated degree certificate ☒ ☐

6 English translated academic transcript ☒ ☐

7 Passport size photo ☒ ☐

8 Scan of passport (cover and identity page) ☒ ☐

9 Health certificate(**) ☐ ☐

10 Certificate of English proficiency (*optional) ☒ ☐

11 Certificate of Bahasa Indonesia (*optional) ☐ ☐

(*) optional.
(**) may be submitted after the admission result announced.

Statement Letter
The undersigned below,

Name : Mona Ali Mohamed elsayh

Nationality : Egyptians

Passport Number :A24999421

Address : Damietta –new Damietta –behind elkafoury street

It hereby states that,

1. I will obey and comply with all rules and regulations in the Republic of Indonesia;

2. I will obey all universityattend lectures in an orderly manner;

3. I will not be working and conducting any actions that will lead to criminal or involve in
any political activities in the Republic of Indonesia.

Thus, I make this statement with the truth without any element of coercion from any party. If in
the future it turns out to be a violation or this statement is not true then I am ready to accept all
the consequences in accordance with applicable law.

Place, Date

Egypt .18-8-2020

*Applicant’s signature

Full name of applicant

Mona Ali Mohamed elsayh

Motivation letter
Aerial, Persil, vanish ah nothing removes those stains. This faint eyeliner and red smear on the once-
crisp white lab Coat motivated me to be a good pharmacologist, not being afraid of breaking barriers
in human interaction and change mindsets to optimize health care practices. Previously I used to be
afraid of taking decisions & being alone. My mother suffered from severe anaphylactic drug reaction
as well as head trauma. In mid of chaos and fear, Dr. Ahmed’s (ER physician) way of handling my
mother’s condition soothed me, as he so delicately lowered my mother’s head and started reciting
jokes to alleviate her pain and anxiety. Seeing the red smear of blood on his lab coat ignited me to
be devotee and loyal, as he was ethical to his profession. From that day onwards, Dr. Ahmed became
my ideal imitated model & symbol in future carrier life. Yet, I have become curious to identify the
causes of my mother’s rapid reaction. Hence, I began searching for the link between drug interaction
and individual fluctuations. Then, I discussed the patient’s history of fatal reactions with ER
physicians. I attended pharmacy school to peruse my curiosity. In college, my professors have
instructed me about the pharmacologist’s role in linking physicians with patients. During my work
placement, I became more aware of the moral consequences of my actions, not only my professional
commitments. One day while doing my usual tasks, I met Ms. Amal, a regular client with a cheerful
and high spirits, being overwhelmed and enthused, her tears mixed with her black mascara stained
my lab coat. I tried my best to calm her down and asses what is wrong with her. She informed me
that” Jana” her three years old daughter, was menstruating. Jana’s condition shocked and puzzled
me as I shared a close relationship with Ms. Amal, I did not want to let my emotions control me and
lose her trust. I consulted my irresponsive manager who instructed me to dismiss the case. Fear
possessed, as my manager used to insult anyone who questioned the validity of any opinion or view
other than hers. I thought that if Dr. Ahmed were afraid, then my mother would definitely die.
Therefore, I began searching for scarce genetic conditions resembling similar symptoms in Springers.
In addition, I examined the clinical results, presented my findings to the physician, and we concluded
that top estrogen levels caused the child’s condition. It was a rare hereditary condition called
Muccine Albright syndrome.I became capable of re-testing healthy boundaries in my relationships.
In addition, I maintained optimistic concerning social change and working with unique minds. When I
experienced fear and failure, I was able to resolve and understand the nature of conflicts. Thus, I was
born to admit other perspectives rather than mine. For that reason, I became open to sharing my
struggle with abusive behavior in stories and poems. Once I have acknowledged fear as a normal
instinct for survival, I became no longer ashamed of it. However, the Indonesian community will
offer me the autonomy to change people’s status quo. As the quality of influence is the critical
determiner of its extent. Besides, a community raising the stakes for democracy and individual
diversity will empower me to demolish health myths and misguided beliefs in my community. My
social awareness will ease the adaptability to myriad minds and tongues.People have never failed
to inspire me, even with little specks of colors. That is why I want to be part of their insightful
journey. I concluded that I found my voice and entity in work placement, but have not found my
path yet, path of having competence & wisdom to affect people’s choices, which certainly be via this
scholarship.