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APPLICATION FORM
Ministry of Public Health of Russian Federation
Saint Petersburg State University
MD/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.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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 and country 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)
Ministry of Public Health of Russian Federation
Saint Petersburg State University
MD/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.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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 and country 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)