Document P1/7.

Modular MBA & Executive MBA Application Form

Please fill in electronically, then print and sign the form.

1. Please indicate the program option you would like to apply to:
Full-time MBA (1 year)
Part-time MBA (2 years)
Full-time MBA in Sustainable Business (1.5 years)
Part-time MBA in Sustainable Business (2 years)
Full-time Executive MBA (1 year)
Part-time Executive MBA (2 years)
Full-time Executive MBA Sustainable Business (1.5 years)
Part-time Executive MBA Sustainable Business (2 years)

2. Entry date - Please indicate the semester to which you wish to enroll:
Fall - Winter Semester (September)
Spring - Summer Semester (February)

3. Personal information and contact details

Mohammad Ali
First Name: _______________________ Middle Name: _______________ Family Name: _______________________
Ghaseminia
Male Female Mr. Email: _________________________________________________
Mr./Mrs./Ms.: ______
ali.ghaseminia@gmail.com
Feb 6th 1986 - Qom, Iran
Date and Place of Birth: _______________________________________________
No. 223, North Taghavi St, Modarres Blvd
Mailing Address: _______________________________________________ Post Code __________________________
3715115897
Qom, Iran
City & Country: ____________________________________________________________________________________
+982536661819 _______
Telephone: _______________________________ B30753070
Passport Number:__________________________
+989126526396
Mobile Number: ______________________________ Iranian
Nationality:_______________________________
Swiss Resident Permit: If you travel on a foreign passport, but have a Swiss Resident Permit or Visa please attach a copy of the document, even if it has expired.

Please submit a digital

passport style portrait
photograph with your Business card
file

4. Education (List the highest degree or qualification obtained)

Degree or qualification obtained(year) by (Institution and location)

Master of Science
______________________________________________
2012
_______________
Amirkabir University of Technology - Tehran
____________________________________
Bachelor of Science
______________________________________________
2009
_______________
Amirkabir University of Technology - Tehran
_____________________________________________

______________________________________________ _______________ _____________________________________________

Document P1.7.2 (December 2016) 1

5. English Level

Mother tongue Excellent Good Fair

If applicable, please indicate the score obtained in the following English test
94
TOEFL /score: ________ TOEIC/score: ________ IELTS/score: ________
6. Work experience (At least 3 years of relevant working experience. Please mention your most recent positions starting with the current one)
Company Name Industry Sector Position Dates
(MM/YY to –MM/YY)

Rayan Azma Espinas Co.

_____________________________________
Computer and IT
________________________
CEO
_____________________________________
01/16-06/18
______________

Amood Gostar Co.

_____________________________________
Construction
________________________
Technology and International Relations Advisor
_____________________________________
02/14-06/18
______________
RaymandTech Co.
_____________________________________
Indivisual Property
________________________
Co-Founder/Board Manager
_____________________________________
07/15-04/17
______________

7. Name and address for Invoices Tick if same as contact details

Please indicate to whose name the invoice for the program fees should be addressed:

Name of Company: ____________________________________________

Family Name Dr./Mr./Mrs./Ms.: _______________________________ First Name: ___________________________
Mailing address: ____________________________________________ Post Code: ___________________________
City: _________________________________________ Country: _________________________________________________
Main Telephone: _______________________________ Email: _________________________________________

8. How did you hear about the Program? (Please indicate the source)

Fair: ___________________________________________ Internet: _____________________________________________________

Financial Times
School rankings: _______________________________ Social media: _________________________________________________

Press article: _________________________________ Print advertising: _____________________________________________

Friend/Family/Colleague: _____________________ BSL faculty: ___________________________________________________

Agent: _______________________________________ High school (counselor/event): ________________________________

Other institutions/organizations: _______________________________________

Career advisor/Employer: _______________________________________

Event/Conference: _____________________________________________

From a BSL former/current student: _______________________________

Business School Lausanne reserves the right to change or modify in part or completely any course description and/or program in the interests of
all parties concerned. The place of legal venue for any dispute shall be Lausanne, Vaud, Switzerland.

I,…………………………………………………………………………………………………, hereby certify that I have read and understood the

“Registration Terms and Conditions” and sign in acceptance of these conditions. I fully adhere to the rules and
regulations of the school. I also confirm that the information entered by myself on the application form is correct.

First name: Mohammad Ali

____________________________ Family name: Ghaseminia
_________________________________
Mohammad Ali Digitally signed by Mohammad Ali

Date: 6/13/2018
________________________________ Signature of applicant:
Ghaseminia
__________________________
Ghaseminia Date: 2018.06.13 22:55:51 +04'30'

Please return your complete

application file to:
Business School Lausanne
Office of Graduate Admissions
Rte de la Maladière 21
1022 Chavannes, Switzerland

Document P1.7.2 (December 2016) 2