APPLICATION
FORM - EICC (fields with * shows
required fields.)
SECTION
A: Personal Information
Mr.
Mrs.
Miss.
Last Name *
First Name *
Second Name
Previous Last Name (if changed)
Date of Birth *
(eg. 1 January 1970)
Place of Birth
Occupation
Present Mailing Address*
Permanent Address *
Province *
Telephone Number *
Business Telephone Number (if any)
Mobile Telephone Number (if any)
Fax Number
Cell Number
Email Address *
Financial Plan
Personal
Family
Govt. Loans/Grants
Others
Govt. Loans/Grants
How you heard about us
Have you ever been arrested/dismissed
from any academic institution?
No
Yes (if Yes please provide details below)
Have you ever been hospitalized
for a physical or mental illness?
No
Yes (if Yes please provide details below)
SECTION
B: FAMILY INFORMATION
Name of Spouse
Father Information
Name
Occupation
Address
Phone
Mother Information
Name
Occupation
Phone
SECTION
C: ACADEMIC INFORMATION
Requested Admission Beginning
Enrollment Desired
Type of Program
College
/ University
Dates
Attended (EG. DATE/MONTH/YEAR)
Diploma/Degree Major
1.
From:
To:
2.
From:
To:
3.
From:
To:
4.
From:
To:
5.
From:
To:
6.
From:
To:
ATTACHMENTS
: UPLOAD DOCUMENTS
Please choose how many
Educational Documents You would like to upload
:
File formats such as : pdf, jpeg, gif are acceptable. Each Filesize should
not be more than 800 kb.
UPLOAD
Document (1)
Document
Name :
REFERRAL OF FRIENDS
Friend's Name
Phone Number
Email
Friend's Name
Phone Number
Email
Please
list below all Documents that will be followed
by Mail :(please seperate by comma)
TELL
US ABOUT YOU!
LEADERSHIP
ABILITIES
EXTRA-CURRICULAR
ACTIVITIES
Future
goals and aspirations
APPLICANTS
DECLARATION :
I hereby declare
that the information I have submitted in this
form is true and correct to the best of my
knowledge. Completion
of this online application form should be followed
by a signed application.
I,
the undersigned, hereby apply for admission
to a School of Medicine. I agree to comply
with the rules of the school, and to co-operate
with the Faculty and Administration in
maintaining high standards of scholarship
and conduct. I certify that all the information
provided in this application and associated
materials is correct, valid, and complete.
I hereby Accept this that I have read
above declaration.
