University of RajshahiInstitute of Biological Sciences

Registration form for MPH (Evening) program Session: 2017-2018, Batch-03

1. PERSONAL INFORMATIONName of the applicant (capital letter):

Father’s name: E-mail:

Mother’s name: Phone:

Mailing/Postal address Fax:

House: Permanent address (if different)

Road/Vill.: House No.:

Post office: Road/ Vill:

Post code: Post office:

Upazilla: Upazilla:

District: District:

Date of Birth (dd/mm/yy) Place of birth Nationality Religion National ID/Passport

NID:

Blood group: Gender: Marital status: Passport No.

2. EDUCATIONAL RECORDDegrees Board/University/Equivalent Roll No. Year Major CGPA

/Div.% of

Marks/Grade

3. EMPLOYMENT RECORD (if any)Present job title: Previous position From To

Dates of joining:

Organization: Address:

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Attach applicant’s recent photograph

Phone:

E-mail:

* Attach extra sheet if needed

4. MAJOR SUBJECTS

Select major subject (only one)

Epidemiology Hospital Management

Dental Health Community Medicine

5. DECLARATION

I hereby declare that the above information is true. I shall abide by the rules and regulations set by the University.

Signature of the Candidate with date

For Office Use Only

6. RECORD OF ADMISSION TEST

Exam year: Exam Roll: Exam score: Merit position:

7. REGISTRATION (if any under RU)Registration No.: Student ID No.: Session:

8. VERIFICATION AND RECOMMENDATION

Signature of Authorized Officer with date Signature of Course Coordinator with date

9. APPROVAL BY DIRECTOR

Signature of the Director with date and official seal

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