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St Petersburg State University
Medical Doctor/Dental Doctor
Nurse Diploma Program
Please print
Name:___________________________;_________________________________________________
Family/Surname First and Middle
Fathers Full Name:___________________________________________________________________
Mailing Address: Please be specific, all official correspondence will be addressed here.
__________________________________________________________________________________
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Telephone Numbers with codes: Home:_______________________ Work:______________________
Email Address:_________________@_________________Mobile:____________________________
Name of College/University____________________________________________________________
Year Graduated________ Degree Earned____________ Language of Instruction_________________
Date of Birth___________ Country of Birth___________City of Birth___________________________
Country of Passport_______________________ Passport No._______________________________
Date Passport Issued_______________________ Expiration Date____________________________
City and Country of Russian Consulate where visa will be applied for:_________________________
Have you ever been denied a Russian Visa ?______________, If yes, when ?___________________
Have you taken TOEFL or IELTS exams ?________, if yes, scores_____________________________
Have you read Mr. Mosqueda's information titled "Green Cards for Doctors"____________________
Acknowledge by placing initials here ______________
Dated:_______________________
Signed_______________________________________________
Print, complete, sign, scan and email