I.K.

AKHUNBAEV KYRGYZ STATE MEDICAL ACADEMY- BISHKEK, KYRGY

REPUBLIC

APPLICATION FORM
For Admission in MD (MBBS)/BDS at KSMA
Academic Session 2016-2017.
NOTE: Candidate is advised to complete all columns of the Application.
Please read the instructions for admission in the Medical institution in
MD (MBBS)/ BDS courses for session 2016-2017 carefully.
Fill in BLOCK LETTERS WITH BLACK PEN.
To,
The Registrar
KSMA
I request for admission in 1st year MD(MBBS)/BDS course for the academic session 2016-2017
as under:

Course applied
for
MD(MBBS)/ BDS
1st
2nd
Choice
Choice
My particulars are given in personal information.

PERSONAL INFORMATION
NAME OF THE APPLICANT (BLOCK LETTERS:)
FATHER'S NAME:
Date of Birth:
Place of Birth:
Male:
Female:
Nationality:
Permanent Address:
Present Address:
Email Address:
Phone No. (Home):
CONTACT IN EMERGENCY
Name of person:
Relationship:
Phone No. (Home):
Mobile No.:
Address:
Date of Submission
ACADEMIC QUALIFICATION
Name of Examination
Passing Year
Name of Board
Total Marks Obtained
Division/Grade
Annual/Supp:

SURNAME:

Mobile No.:

Signature of Applicant
Matric Science/O Level

Inter Science/ A Level

IMPORTANT NOTE FOR CANDIDATE

Incomplete application forms including those with short documents shall not be entertained and will be rejected.

All candidates are advised to submit his/her application form and required documents in a decent file cover to
avoid any misplacement/displacement of documents.

AFFIDAVIT
I, --------------------------------------------------------------S/o, D/o -------------------------------------------------- a
Candidate for admission in 1st year MD (MBBS)/BDS for academic session 2016-17 do hereby state on solemn
affirmation/ oath as under:
1. I solemnly declare that all the particulars mentioned in the admission application are true and correct and
I fully understand that if any of the statements made in the application is found to be incorrect, I would
be liable to refusal for admission to the KSMA, if otherwise eligible for admission and admitted, would
be liable to be expelled from Institution at any time during course of my studies in which case all fee and
other dues paid by me to the KSMA shall be forfeited and I will be liable to any further departmental or
legal action which the KSMA may deem fit to take.
2. I also solemnly declare that, if admitted, I will abide by the disciplinary rules and regulations of the
KSMA as enforced at present and amended from time to time by the KSMA authorities in future. I will
concern myself only with the academic activities and such extracurricular activities, which are allowed
by the KSMA for the healthy growth of body and mind. In matters of discipline, the decision of the
Rector will be final and binding on me and I will not challenge that decision in any court of law in the
Kyrgyz Republic. I will be regular in paying KSMA dues and will be punctual in attending my classes. I
will not absent myself from teaching programmes without prior permission of the authority.
3. I undertake that so long as I am a student of the KSMA, I will do nothing either inside or outside the
KSMA, hostels and hospital premises that may interfere with its orderly administration and discipline or
may bring bad name to the KSMA.
4. I fully understand that if I fail to clear the competitive Entry Test, I shall cease to be eligible for further
medical education in KSMA this year.
5. I fully understand that if any of the documents submitted by me is found to be bogus at any time during
the years of MD(MBBS) course, I shall stand ineligible for medical education in KSMA.
6. If I violate the above affidavit I shall be liable to appropriate punishments by the law.

-------------------------------------------------(Name of the Candidate)

---------------------------------------------(Signature of the Candidate)

Address: -----------------------------------------------------------------------------------------------------------------Passport No. ----------------------------------------------- Dated: ----------------------------------------------------Counter Signature of Student's Father/ Guardian:
Father/ Guardian's Name :----------------------------------------------------- Signature: ---------------------------

Relation with applicant:-------------------------------------------------------- Dated: -------------------------------