Funded Under the Second Health Sector Development Project Component II

Application form for Master of Science Degree in Health Economics,

funded under the Second Health Sector Development Project Component II

1. Full name of the applicant

1. Name with Initials of the applicant

1. Designation of the applicant

1. Current Place of Work of the applicant

1. National Identity card Number of the applicant (Please attach a certified copy of the NIC)

1. Number of Passport (Please attach a certified copy of the Passport)

1. Contact Details of the applicant

Office Address
Office Phone Number
Office Fax Number
Mobile Phone Number
Home Phone Number
Home Address
Email Address

1. Date of Birth of the applicant (Please attach a certified copy of the Birth Certificate)

YYYY / MM / DD

1. Age as of 30th October 2015

YY / MM / DD

1. Education Qualifications

Details of the Basic Degree (please attach a certified copy of the degree certificate)
Name of the Degree
University
Date of Qualification
Details of the Masters of Science Degree (please attach a certified copy of the degree certificate)
Name of the Degree
University
Date of Qualification
Details of the other Degrees possessing (please attach certified copies of the degree certificates)
Name of the Degree/s
University
Date/s of Qualification

1. Are you a confirmed officer of Medical Service

Yes / (Please attach a copy of the confirmation letter)
No

1. Posts held in Department of Health in chronological order

No. / Post & Station / Period
From
(YYYY/DD/MM) / To
(YYYY/DD/MM)

Declaration of the candidate

I certify that

1. The above particulars furnished by me are true and correct.
2. I am willing to serve in the public sector for 5 years after completing the MSc in Health Economics if selected.
3. I am of good physical and mental status to undertake the training in a foreign country.

Date: ______(DD/MM/YYYY) / Signature of Applicant

Recommendation of the Head of the institution

Recommended / Not recommended

I certify that above particulars given in the application are true & correct. He/ she can be released for the MSc in Health Economics training programme, full time, if selected.

Date: ______(DD/MM/YYYY) / Signature and Stamp of the Head of the Institution

Recommendation of the Head of the decentralized Unit

Recommended / Not recommended

I certify that above particulars given in the application are true & correct. He/ she can be released for the MSc in Health Economics training programme, full time, if selected.

Date: ______(DD/MM/YYYY) / Signature and Stamp of the Head of the decentralized Unit

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