H-MBA Application Form

Southern MedicalUniversity

Mater of Science Application Form

1. PERSONAL INFORMATION

Please complete in BLOCK CAPITALS only

Family name: ______

First name(s): ______

Male / Female Marital status: Single / Married

Date of birth: ______(day) ______(month) ______(year)

Place of birth (City, Country): ______

Citizenship: ______

a) Current home mailing address: Street: ______

City: ______Postal code: ______

Country: ______

Telephone: ______Mobile: ______

Personal e-mail: ______

b) Permanent home mailing address (if different from above): ______

City: ______Postal code: ______

Country: ______

Telephone: ______Mobile: ______

Preferred mailing address for communication: Current home  Permanent home

2. EDUCATION

List in chronological order the post-secondary institutions you have attended. Copy of highest degree diploma required.

English Language Proficiency

If you have ever taken the TOEFL or IELTS, please fill in the following items.

 TOEFL Date: ______Score: ______TWE Score: ______

 IELTS Date: ______Average Score: ______

3. EMPLOYMENT RECORD

If you have graduated and worked, Please complete the Blank below in BLOCK CAPITALS only

PRESENT EMPLOYMENT

Company name: ______

Parent company: ______

Company address: ______

City: ______Postal code: ______

Country: ______

Direct telephone: ______

General Telephone: ______

Direct fax: ______

Company website:______

Your e-mail: ______

No. of employees (please state year): ______

Annual sales of your organization (please state year): ______

Industry: ______

Employed with current company since: ______

Current function/Job title: ______

Level of responsibility:  Senior to top management  Middle management Expert

No. of persons supervised: ______

Main area of expertise: ______

Brief description of current responsibilities: ______

______

______

EMPLOYMENT HISTORY*

Please describe your previous full-time positions:

Total years of full-time work experience: ______

Total years in management positions: ______

* Please include a copy of your CV with your application

4. REFEREES

Application cannot be processed until references are received. Applicants are responsible for ensuring that references are sent by their referees. Please give the names, addresses and positions of your referees below.

1st Referee 2nd Referee

Name:______Name:______

Position:______Position:______

Company:______Company: ______

Address:______Address:______

______

Telephone:______Telephone:______

5. Finance:

Applications for Full-time Mater of Science

Please indicate how you intend to finance your MS fees / living expenses. Your funding will not impact the admission decision.

Personal Savings: ______% Salary Sacrifice: ______%

Employer Sponsorship: ______% Scholarships: ______%

Parent: ______% Other: ______%

6. DECLARATION:

I certify that the answers and other information given in this application are correct andcomplete. If my application is accepted I undertake to observe the Southern Medical University regulations, to ensure full payment of fees and to accept all liabilities.

Signature of Applicant: ______Date: ______

7. CHECKLIST:

Before submitting your application form, please check that you have included:

Fully completed and signed application form

Two recent passport photographs (one attached to the application form and one additional)

Copy of highest degree diploma (verified and in English)

Your CV