NOMINATION / APPLICATION FORM

MASTER OF PUBLIC HEALTH

2018 - 2020

(To be filled in by the nominee / applicant in capital letters)

Upload photo:

Name and Surname: 

Gender: M  F     Age:    Date of Birth:    Nationality:

ACADEMIC BACKGROUND

 Level of Academic qualification   Degree  Subject / Stream  Board / University 

 College / Institution 

of Affilliation

 Year of 

passing

 Final percentage 

Grade / Class

 Class X  N/a
 Class XII N/a
 Bachelors/Under-graduate degree 

 Masters/Post-graduate degree or

 any other equivalent qualification

 Any additional

 Qualification / Training

 

PG ENTRANCE

Have you given PG Entrance exam? Yes  No

  • If answered yes to previous question:
    • Full name of entrance exam:
    • Year of appearance in exam:
    • State (if specific to any state):
    • Score (percentage / percentile):

 

WORK EXPERIENCE (Internship not be counted in experience)

Total work experience in years:

 Duration of Employment   Name of Organization   Designation   Roles / Responsibilities 
 Current
 Past

 

LIST OF RECENT ACADEMIC AWARDS / ACHIEVEMENTS (Including publications / presentations)

EXTRA CURRICULAR ACTIVITIES

Do you belong to SC/ST/OBC/PH?: Yes / No
(If Yes, Please specify category: , please attach self-attested copy of certificate)

ENCLOSURES: (Please do not send any original certificates, they are to be produced only at the time of personal interview)

  • Application fee of Rs.500/- (US$8 for internation and SAARC candidates) drawn on Indian Institute of Public Health Gandhinagar to be paid along with the application form. (Send yourt payment Ref. No & Receipt No. on This email address is being protected from spambots. You need JavaScript enabled to view it.)
  • Necessary copies of all academic statements from Class X onwards and PG entrance exam results. 
  • Copy of resume / curriculum viteae
  • Contact details of 3 referees: two academic + one professional (if some work experience)
  • Statement of purpose (This needs to be a 250-500 words summary, written completely by the candidate, stating professional goals and career plans, including plans and expectations in pursuing MPH Programme).

 

Payment options: (A/C Holder Name: Indian Institute of Public Health Gandhinagar; Bank Name: HDFC, Bank Ltd.; Branch Name: Astral Towers, Opp. Reliance General Insurance, Nr. Mithakhali Six Road, Navarangpura, Ahmedabad-380009, Gujarat, INDIA, A/C No.: 50100157403005, IFSC Code: HDFC0000006, BIC/Swift Code: HDFCINBBAHM, MICR Code: 380240002) / demand draft / cheque payable at par at Ahmedabad.

(THE LAST DATE FOR THE ACCEPTING APPLICATIONS IS 31ST MAY 2018.)  

Source of information about MPH Course in IIPHG:
APPLICANTS ADDRESS FOR COMMUNICATION:
CITY:
COUNTRY:
PINCODE:
PHONE (Resi.):
FAX:
MOBILE:
EMAIL:
DATE:
 
Upload documents:
  • Necessary copies of all academic statements from class X onwards and PG entrance exam results
  • Copy of resume/ curriculum vitae
  • Contact details of three referees: two academic + one professional (if some work experience)
  • Statement of purpose (This needs to be a 250-500 word summary, written completely by the candidate, stating professional goals and career plans, including plans and expectations in pursuing MPH Programme)




Required documents should be posted to:

Assistant Manager (Academic Programmes)
INDIAN INSTITUTE OF PUBLIC HEALTH GANDHINAGAR
University established under IIPHG Act 2015 of Gujarat State
Opposite Air Force Head Quarters, Near Lekawada NBus Stop,
Gandhinagar-Chiloda Road, Lekawada, CRPF. P.O. Gandhinagar - 381042, Gujarat, INDIA
Phone: +91-79-66740700; E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it., This email address is being protected from spambots. You need JavaScript enabled to view it.
URL: www.iiphg.edu.in, www.phfi.org