NOMINATION / APPLICATION FORM

MASTER OF PUBLIC HEALTH

2017-2019

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* Name & 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/PG Degree or any other equivalent quali.
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

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 answered yes to previous question:)

Specify category:
Attach self-attested copy of the certificate:


ENCLOSURES: (Please produced any original certificates at the time of personal interview)

  • * Necessary copies of all academic statements from class X onwards and PG entrance exam results

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  • * 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)


Source of information about MPH Course in IIPHG:

* APPLICANTS ADDRESS FOR COMMUNICATION:
* CITY:
* COUNTRY:
* PINCODE:
* PHONE (Resi.):
FAX:
* MOBILE:
* EMAIL:


Date:


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