Application for Admission to The Graduate School

of Chulalongkorn University, Academic Year ............

Application No.
Code :

0 0

Photograph

Programme : M.Sc. in Health Economics and Health Care Management, Faculty of Economics
Type or write in capital letter
1. Name and title
Mr.
Mrs.
Miss
Other
Full name and surname using capitals. Leave two blanks between name and surname

2. Date of birth
Nationality
Home address

/19

Place of birth
Religion

Age

Years

ID/Passport no.
E-mail:

3. Marital status
Single
4. Present mailing address

Married

Other
Postal code

Telephone

Tele Fax

Country
E-mail:

Documents Required with Application

Please tick in the boxes provided to indicate submission of each document
For Official Use
Only
1
Application form with photograph attached
2
Photo copy of previous degrees and certificates
3
Transfer for $35 or 800 Baht to Chulalongkorn University, Faculty of Economics
Bangkok Bank, Siam Square Branch, account no. 152-021753-8, swift code: BKKBTHBK
4
Official transcript from the University previous attended
5
Statement from employer confirming that leave will be granted
6
Photo copy of identification card
7
Photo copy of marriage certificate (ONLY if current name is different from other documents)
8
TOEFL, British Council, or equivalent English language test results
9
Recommendations from two unrelated persons who are able to evaluate academic and/or professional
performance
10
Description of current function, responsibilities and activities. (No more than one A4 typed page)
11
An essay no more than one A4 typed page on My future career aspirations.
12
Areas of research interest. No more than 1/2 A4 typed page
13
Photo copy of first 4 pages of your passport
14
Four (4) 1-inch-colored photos (with blue background)
15
Others?
Total number of documents submitted
I hereby certify that all the documents submitted are valid.

Signature :
Date :

Where documents are found to be INVALID the University will revoke the admission agreement and retain all
payments made to the University.
This application and all documents should be received by the end of February the following year.

Certificates and Degrees received at university level

Type

Name of University or Institution

Date

Title/Topic

Date

Major Field

List of recent publications

Authors/Co-author

Publisher

Employment record
Position

Organization

From-to

Name, position and address of three referees

1.
2.
3.

Financial Support
Partial financial support

Self support

Expected

Agreed

Full financial support

Sought

Expected

Agreed

No financial support

Self support

Other

Name and address of expected financial source

Address, telephone/tele FAX

Level