M. M. Madazimov

Rector Andijan State Medical Institute_

(Name of the higher educational institution)
________M.M. Madazimov_______________
___________________________________________________

(FULL NAME)

From_________________________________________________________________________

(Full name of the student (written in full)

APPLICATION

I ask you to allow me to provide the necessary documents to the admissions committee for enrollment in the form of study ________________________________________________

(full-time, special correspondence)

in the direction of education _________________________

(code and name of the direction of education)

_________________, in ___________________________________the language of instruction.

(Russian, English, Kazakh, Tajik, Turkmen, Kyrgyz)

Scored _______ point and credited on __________________ or ________________ basis.

(contract) (grand)

Education___________________. Graduated from _____________________________________

(secondary, specialized secondary, higher) (name of educational institution)

______________________________________________________________ in ________ year.

Education document (certificate, diploma): series ___________ No. ______________________

According to the document on education, I have mastered (s) ___________________________ (name of foreign language (s)

________languages.

Date and place of my birth: _______ year ___________________, __________________
Permanent residence: _________________________________________________________

(permanent residence is indicated in the passport (republic, region, city, district, village, street, house and apartment number) in full).

______________________________________________________________________________

Passport data: _________ _________________, ___________________

(series) (number) (issued by whom and when)

_____________________________________________________________________________

Work experience (if any) __________________________________________

(last place of work, position, period of work)

______________________________________________________________________________
Information about the parents:

Father_____________________________________________________________________________

(full name, working place)

_____________________________________________________________________________

Mother_______________________________________________________________________________

(full name, working place)

______________________________________________________________________________
Information about participation in international and republican Olympiads, competitions and sports competitions (if took part)_____________________________________________________________

(subject of the Olympiad,)

______________________________________________________________________________ discipline (specialty) of the competition, type of sports competition, date of the competition, place taken)
I report the following about myself:

Information about disability (filled in by a disabled applicant):

__________________________________________________________________________________

(type and group of disability (a copy of the document confirming disability is attached)

Information about orphanhood (full orphanhood) or loss of a breadwinner (filled in by the applicant as an orphan (full orphan) or who has lost a breadwinner):

_______________________________________________________________________

(number and date of the certificate (certificate of the registry office) about the death of the father, mother (father and mother) or breadwinner (a copy of the certificate (certificate) is attached)
Information about the stay in the "House of Orphan " (filled in by the applicant by the pupil):

_____________________________________________________________________________

(the name of the " Orphan House") (a copy of the certificate of stay in the "Orphan House" is attached)
I am familiar with the procedure for conducting tests and the rules for filling out the answer sheets.
_______________________ ___________ ________________________

(Name of student) (signature) (date of application)