MINISTRY OF HEALTH OF UKRAINE

MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE

LUGANSK STATE MEDICAL UNIVERSIT Y

www.lsmuedu.com Kvartal 50-Let Oborony Luganska,1 91045,Ukraine Tel: +38(0642)63-02-63 Fax : +380(0642)53-20-36 APPLICATION FORM FOR ADMISSION AS ASTUDENT AT LUGANSK STATE MEDICAL UNVERSITY FOR FOREIGN APPLICANTS
(You can get this form from www.lsmuedu.com; Photostat copy of this also may be used as application for admission into University) (CAPITAL LETTERS ONLY)

1) YOUR PERSONAL DETIALS (enter exactly as contained in your educational certificate and passport)
Surname First & Middle Name Date OF Birth Gender Nationality Address Country of Residence Visa Issuing Place International Passport No Issued on Valid to Telephone No E-mail
M F

2) YOUR EDUCATIONAL BACKGROUND

Qualification Secondary / Matriculation Higher Secondary / Senior Secondary / Intermediate Graduation / Degree / Diploma Name of Examination Name of University / Board Year of Passing Grade / Point / Percentage

3) FACULTY THAT YOU WISH TO APPLY FOR

Desired Course Foundation Course Premedical Course Dental Medicine Pharmacy Nursing UG / PG Medium of Instruction ( English / Russian ) Department For PG Course

4) LIST OF DOCUMENTS TO BE SEND WITH THE APPLICATION

Scand copy of Educational Certificates Scand copy of Passport ( Main pages ) Scand copy of Birth Certificate Online Payments Details

5) FINANCIAL SUPPORT
Self Financed Y N Bank Loan Y N Scholarship Y N

6) OTHER APPLICATIONS
Have you ever applied for any other Educational Institution in Ukraine ? If yes, furnish the details

7) SPECIAL RESONS FOR CHOOSING OUR UNIVERSITY

8) SWORN STATEMENT
I confirm that to best of my knowledge and belief that all the information I have given on this form is true , complete and accurate . I have enclosed the required documents (certificates, supporting documents , etc). I am aware that intentionally or negligently giving false information constitutes an administrative offence and may lead to exclusion from the admission procedures or if discovered at letter date to the cancellation of my admission or enrolment .

Place:

Date :

Signature :

Name :

N.B MAIL THE FILLED FORM ALONG WITH DOCUMENS TO info@lsmuedu.com N.B Please use a separate paper if you wish to provide any further reasons for your application . The above information will be stored and processed by the Ministry Of Health of Ukraine and Ministry of Education and Science of Ukraine and Lugansk State Medical University .