APPLICATION  FORM
                        Ministry of Public Health of Russian Federation
          Saint Petersburg Medical Academy of Postgraduate Studies
                                            MD/Nurse Diploma Program
                        
 http://www.maps.spb.ru/eng/studies/nurse.html


                                                                                    Please print


Name:___________________________;_________________________________________________
Family/Surname                                    First and Middle

Fathers Full Name:___________________________________________________________________

Mailing Address: Please be specific, all official correspondence will be addressed here.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Telephone Numbers with codes: Home:_______________________   Work:_____________________

Email Address:________________________@_______________. Mobile:______________________

Name of Medical 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 in India where of visa will applied for at Russian Consulate:_______________________________

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 "Practice Medicine in the USA"________

Do you understand that as a condition to being admitted into the MAPS English language MD/Nurse
program, you will have to be personally represented by Mr. Rudolph Mosqueda for placement in the
US as a nurse once you earn your CGFNS Certificate? Please initial to Acknowledge_______________

Dated:_______________________ Signed________________________________________________
(Please print, complete, sign, scan and e-mai)