QUESTIONNAIRE

Surname:

Name:

Middle name:

Date of birth:  

Nationality:

Gender:

Passport no:
Issued on:
Valid till:

Home address:

Correspondence(mailing) address if different from above:

Country where you plan to get visa:

Tel. #:

Fax:

Mobile phone:

Email:

Availability of secondary (high) school or college education:

Documents which can prove your level of education:

I ask you to admit me to:  Pre-University Department Pharmacy

Language of instruction:

Please fill out this form and also attach the copy of your international passport and the copy of the document which can prove your level of education (high (secondary) school or college certificate)