Title :
Last Name : *
First Name : *
Middle Name :
Gender : Male Female
Field of study requested :
Date of Birth: Day : Month : Year :
Country of Birth: *
City of Birth:
Country of Residency: *
Marital Status:
Contact Details
Mailing Address : *
Postal code :
Town/City : *
State :
Country : *
Cell phone : *
Work Dial :
Home Dial : *
Email address : *
Work/Home Fax :
Program name :
School :
Degree :
Academic qualification

Please add your study history, completed or attempted after secondary school, and relevant to this course application. Provide as much detail as possible so that we can give your application the consideration it deserves.

index Course Name Degree Of Study Country Institution Name Last year of Study Completed(yes)
Please attach your C.V. in support of the details provided.   
Have you ever been refused entry to, expelled or excluded from another academic institution?
If “Yes”, provide the details :
Do you owe fees to another academic institution?
If “Yes”, provide the details :
Work History
Please list your work history (beginning with your most recent). Attach a separate sheet if the space below is insufficient. Provide as much detail as possible so that we can give your application the consideration it deserves.
index Position or Job title Start date End date Full time or Part time Employer Industry
Please attach your resume in support of the details provided :   
Scholarship And Details
Name of a person/ organization expected to pay your fees (e.g.: the name of an Employer, Sponsor or Yourself):
Do you wish to apply for financial assistance? Yes No
English Proficiency
Was English the language of instruction at your school/college/university? Yes No
English Language proficiency test score : IELTS: TOEFL: CBT: IBT:
- I have fulfilled all requirements required to be eligible for consideration.
- To the best of my knowledge, the information given in this application is correct and complete.;
- I understand that submitting false or misleading information may result in any offer of a place withdrawn at any stage, including after a course has commenced.
- I understand that the University reserves the right to vary or reverse any decision made on the basis of incorrect or incomplete information.
- The University is under no obligation to consider an application submitted after the due date.
- I acknowledge and accept the full enrolment terms and conditions that govern this application form.
- I understand that Iran University of Medical Sciences collects, stores, and uses personal information in accordance with the University's Privacy Policy.

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