UNIVERSITY OF AGRICULTURAL SCIENCES AND VETERINARY MEDICINE
“ION IONESCU DE LA BRAD” IASI
APPLICATION FORM
JULY 2017
STUDIES APPLIED / DOCTOR OF VETERINARY MEDICINE / D.V.M.FACULTY / VETERINARY MEDICINE
FIELD OF STUDY / VETERINARY MEDICINE
SPECIALTY / VETERINARY MEDICINE
I.1. / APPLICANT’S PERSONAL INFORMATION:
1 / Surname
2 / Previous surnames, if applicable (before marriage e.g.)
3 / First name
4 / Personal identification number
5 / Date of birth (YYYY/MM/DD) / / / /
6 / Place of birth / Country:
______/ Region:
______/ City/Village:
______
7 / Parents first names / Father: / Mother:
8 / Gender / F / M
9 / Marital status / Married / Single / Divorced/Widow(er)
10 / Citizenship / Romanian, residing in Romania / abroad
Other citizenships …………………………………………………………………….
Previous citizenship, if applicable...... ………………………………......
11 / Ethnicity: / ………………………………………………………………………………………….
12 / Current permanent residence: / Country:…………………………...…, Region: ………….…………………………..
City/Village: ………………………………………………………………..…………..
Str. ………..…………………..………., No. …......
13 / ID/ Travel document / Type ______Serie______Number ______Issued by______
Date of issue______Valid before(date) ______
14 / Other personal information / Phone no: ______
E-mail: ______
I.2.a. / EDUCATION BACKGROUND (HIGH-SCHOOL GRADUATE)
1 / Secondary school/High-school / Name of the institution
Country
City
Region
Profile/domain
Duration of studies
Year of graduation
Mode of study
(full-time/part-time/distance/evening school)
2 / Diploma / Certificate of studies information / Type (Baccalaureate degree or equivalent for applicants who have studied abroad)
Serial number
Issued by:
Year of issuance
Registration number of the transcript of records
3 / Additional informations / Serial number of the certificate of recognition of studies (issued by DGRIE/DGIS/CNRED)
I.2.b. / EDUCATION BACKGROUND (UNIVERSITY GRADUATE/STUDENT)
1 / Undergraduate studies / Country
City
Region
Name of the institution
Faculty/College
Domain/Field of study
Program of study
Degree conferred
Mode of study (full-time/part-time/distance)
Duration of studies (number of years or semesters)
Year of graduation
2 / Diploma information / Type – name (diploma / Bachelor’s degree / master’s degree)
Serial number
Issued by
Year of issue
Transcript of records’ number
3 / Additional informations / Serial number of the certificate of recognition of studies (issued by DGRIE/DGIS/CNRED)
I.3. / ADDITIONAL INFORMATION
1 / Grades average from the high-school years / ,
2 / Grades average at the high-school final exam (Baccalaureate) / ,
3 / Do you request accommodation during studies? (Y = Yes; N = No)
4 / Processing fee, receipt number...... ………………………………………………………………………
5 / Are you participating in another admission process? (Y = Yes; N = No)
6 / How did you hear about the admission: / newspapers / radio / TV / High-school
University’s website / brochures / Other sources
I, the undersigned, declare the above on my own recognition.
I hereby declare that I do not suffer from any chronic or psychiatric illness.
I also declare that I have acknowledged the stipulations of the Methodology of admission for the academic year 2016-2017.
Candidates declared admitted must sign the Contract of study and submit their original diploma and/or transcript of records within 3 working days. Candidates who fail to enroll before this date will not be accepted.
Date Signature
______
Application Form – Veterinary Medicine / 1 / 2