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www.ph.buu.ac.th

APPLICATION FORM FOR GRADUATE ADMISSION

ewritten or block letters)

IJISTW^afWrTS (IDENTIFICATION OF APPLICANT) muihsf

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Name (Mr. /Ms. /Mrs.)

ftuflBUlllfVa (Date of birth)

WY1 (Day) W8T4 (Month) . . . ll (Year)

iftoYlfwfo (City of birth)

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IflflVllbsilYm (Country of birth)

IWlfJjTIJni (Applicant's ID)

Family name ... .....

fflrtan (Religion) fftyiflfi (Nationality)

IVIff (Gender)

O ¥10 (Male) O ItfD^ (Female)

H{nWfl1flfmff»J5Zr (Marital status)

O Tfffl (Single) O 119144111 (Married)

jilriioiww 1 vn

(1 inch Photo)

(MAILING ADDRESSES)

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(Applicant's permanent mailing address: Number, Street, City, State, Postal Code, Country)

IvnrTrirffiilH'U (Home telephone) TviSffMifflaoa (Mobile phone) I

lllMVIrt (Country code) itffl (Area code) mwinu (Number) lilSirifl (Country code) jiTn (Area code) linuMWiu (Number)

i-mail address:

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(Applicant's office mailing address; Number, Street, City, State, Postal Code, Country)

Tvil^vcn^l-Jiu (Office telephone)

llismrt (Country code) -«T a (Area code) laiiMUiu (Number)

Tnjmi (Fax. No)

iJtsiMff (Country code) IMP (Area code) inDMJJIU (Number)

ljflfla?itnui3fl«fl«101'UfttfSvjm«'U : VO M}J1t(milTriTr?M>1 imswey (Person to be contacted in case of emergency: name, telephone and address)

(APPLICATION DATA) I I am applying to Faculty of Public Health: (select one)

(Program) ...................................................................... fllinwi (Program of Study)

llftytyi (Degree Desired): O ll-ltyfyiTn (Master's) O iJltytynsn (Doctoral)

-time) O llljuluiwunm (Part-time) O HafiqflfW1T41K1« (International program) O UfOl n (2) O 11HT4

fl1fll1{mfif?{Hfmerjmt (Enrollment Semester): O mnqqiou (Summer, March) O mniSoUM 1 (I'semester, June) O mntlflUVl 2 (2"semester,November)

ll W.ft. (Academic Year)

flWlWtflM (Continue Overleaf)

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TERTIARY EDUCATION RECORD (begin with most recent institution attended)

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Name or institution, city and country

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Major fields of study .

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Years of study:

From........ to..*.

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(Degrees abbreviation)

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GPA

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List any relevant awards, publications, scholarships, honors held

(EMPLOYMENT RECORD)

(Current occupation and position)

Occupation . Position

5SlJll5S1iail'JSa'lini3tumT111-5TU (TIU'tf^UvillJlMJJntn) List chronological record of work experience (include part-time experience)

siitmiH (Position) YflTiihcNiul.tisfrniu'in

(Name and address of company)

isosnm vi.fT fa «.ft

(Years of service: from to )

(STATEMENT OF PURPOSE) If additional space is required, please attach a separate sheet.

Please describe briefly your past experiences, your goals and your reasons for choosing your field of study.

.si] O oytywRelease of Information: All information provided on this application is subject to public disclosure unless otherwise authorized by the applicant.

Please check the appropriate box OYes ONo

iii.flfl*lwi8^I certify that my statements given in this application together with all supporting documents are correct and true.

ljVn (Signature of applicant) .......................... . .......................................... a-nwfl (Date)

TT15.038- 102743

Please send to:

DEAN, FACULTY OF PUBLIC HEALTH, BURAPHA UNIVERSITY

20131 Bangsaen, Chon Buri 20131, THAILAND

1-393471 Tel. 66-38-102743 Fax:66-38-393471

INSTRUCTION SHEET FOR APPLICANTS TO FACULTY OF PUBLIC HEALTH

All items described below are required before a decision can be made

O I. APPLICATION FORM

O 2. Three 1 inch recent photographs.

O 3. TRANSCRIPTS: Submit 1 official transcript from each college or

university attended.

O 4. LETTERS OF RECOMMENDATION: Have at least 2 former

instructors or employers submit Letter of Recommendation

regarding your abilities and potential for graduate study (Form-R).

O 5. ENGLISH PROFICIENCY: If your official native language is not

English, the applicant must submit TOEFL or MICHIGAN TEST or

IELTS test scores. Test must be taken within 2 years.

O 6. APPLICATION FEE: Submit a nonrefundable processing fee

(US $ 15.00) with your application. Send post-dated cheques, money

orders or bank draft drawn on bank in Thailand only and indicate

the applicant's name, made payable to:

DEAN

FACULTY OF PUBLIC HEALTH

Burapha University

Bangsaen, Chon Burl 20131, THAILAND

O V.Medical Examination Record issued by a physician indicating that

the applicant has no known disease that might interfere with

graduate studies.

8. Other document submitted: (Specify):

O 1.•i

O 2. jilthauuifl i ui swiii 3 |il

O 3. thivn iTonihsflifliibsTiinj i ntfu

O 4. tfiiui vtmvjivui«Wj«SfniSrrailufuim-jfliirfnuiwiJfiytyiflliiflsluiiafl-iwamsSnin (Transcript)

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Application documents checked by:.

NO APPLICATIONS WILL BE PROCESSED UNLESS

ALL REQUIRED DOCUMENTS AND FEES ARE RECEIVED

BEFORE THE DEADLINE.

APPLICATIONS RECEIVED AFTER THE DEADLINE

WILL BE PROCESSED FOR THE FOLLOWING SEMESTER.

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