Download Medical University of Silesia in Katowice German Students Office

 Medical University of Silesia in Katowice
German Students Office
Pariser Platz 4a
10117 Berlin
GERMANY
APPLICATION
to the Dean
of the Medical University of Silesia in Katowice
Please accept my request for admission / transfer * to the English language medical program
at the School of Medicine in Katowice, Medical University of Silesia in Katowice for the
winter semester of the academic year 2015/2016 for the _____ year of study.
(* Please circle one option)
In case of admission to 1st year of study please check one option below:
American MD program
European MD program
Last Name:
First and/or Middle Names:
Date of birth (dd/mm/yyyy):
Passport number:
Place of Birth:
Nationality:
Citizenship:
SSN
(Social Security Number):
Marital Status:
Father’s Name:
Mother’s Name:
1 Permanent Mailing Address
Country:
City:
Street:
Postal Code:
Phone Number:
E-mail:
Temporary Mailing Address
Country:
City:
Street:
Postal Code:
Source of Income: * please circle one option
Self-financed
Other (please specify)
Financial Aid
Family Support
High School Attended
Name of High School:
Country:
City:
Date of Graduation
(dd/mm/yyyy)
College/University Attended:
Name of College /
University
Country:
City:
Date of Graduation
(dd/mm/yyyy)
2 I have enclosed the following documents to this application:
Item
Title
Please mark
with ’X’
1. Application Form
2.
Notarized copy of university entrance diploma with apostile, translated
into English
Notarized copy of school certificate with the course of subjects biology,
3. chemistry, and physics (if any of these subjects are not presented on the
university entrance diploma), translated into English
4. Copy of identification document (passport)
5. 3 passport photographs
6. Copy of birth certificate
7. Health certificate confirming no objections to begin medical studies
Certificate documenting English language fluency level (required only if
8.
CEFR level is not presented on university entrance diploma)
9.
Receipt of registration fee payment
biology and chemistry / biology and physics / chemistry and physics
During the examination I would like to be evaluated in the following fields of study*
*please circle one option
I hereby confirm that:
The data stated above is correct,
I have read and understood both Study Regulations and Payment Regulations adopted by the
Senate of the Medical University of Silesia in Katowice.
I will pay tuition fees in USD / EURO
I consent to the processing of my personal data included in this Application for the need of
study process at the Medical University of Silesia in Katowice
(in accordance with the Act of Personal Data Protection of August 29, 1997, Journal of Laws
No 10 of year 2002, item 926 with further amendments).
Date ___________________________
Signature ___________________________
3