FORM: A
APPLICATION FOR ADMISSION OF INTERNATIONAL STUDENTS
INSTRUCTIONS:
1. The application should be typed if possible, or neatly handwritten in block letters.
2. Year should be written using the Anno Domini system. Proper nouns should be written in full and not abbreviated.
Personal data entered in this application will only be used for admission, scholarship selection purposes, and contact
information such as e-mail addresses will only be used for forming related human networks after the student returns home
and for sending of information by Mahidol University.
1. ADMISSION INFORMATION
I wish to apply for:
Level
 Higher Diploma
 Master’s degree
 Doctorate degree
Program Code
NONE
Program Name
Residency training in Orthodontics (International Program)
Faculty/ Institute
Faculty of Dentistry, Mahidol University
 First semester
Paste a passport
photo taken within
the previous 6
months.
Academic Year
Write your name
and nationality at
the back of the
photo.
(4.5cm x 3.5cm)
2. APPLICANT INFORMATION
Name
(Family name)
(Given name)
 Mr.
Title:
 Mrs.
 Miss
Gender:
 Male
 Female
Marital Status:
 Single
 Married
Date of Birth:
Date:
Nationality:
(Middle name)
Month:
 Divorce
 Widowed
Year:
Passport No:
Expiry Date :
Email:
Address in Home Country:
Address:
City/Town:
Country:
Postcode:
Phone:
Mobile:
Fax
Correspondence / Current Address: (if different from address in home country)
Address:
City/Town:
Country:
Postcode:
Phone:
Mobile:
Fax:
3. EDUCATIONAL BACKGROUND
Educational level
Undergraduate Level
Graduate Level
Name and address of Institution
Year and
Month of
Entrance and
Completion
Name :
From
Location:
To
Name:
From
Location:
To
Name:
From
Location:
To
Diploma or
Degree awarded
/ Major subject
* If the blank spaces above are not sufficient for the information required, please attach a separate sheet.
4. EMPLOYMENT RECORD: Begin with the most recent employment, if applicable.
Name and Address of
Organization
Period of
Employment
Position
Responsibility / Type of work
From
To
From
To
5.ENGLISH PROFICIENCY: Evaluate your level and insert an X where appropriate in the following blank space.
Excellent
Good
Fair
Poor
Reading
Writing
Speaking
Listening
5.1. Is English your first language?
 Yes
 No
5.2. Is English the main language spoken in your home?
 Yes
 No
5.3. Were your studies at university conducted in English?
 Yes
 No
5.4. Have you taken any English proficiency test in the last 2 years
 Yes
 No
(TOEFL / IELTS)?
Name of the test*
Test Date
Earned Score:
* Please add certificate of English profiency test
6. PROFICIENCY OF OTHER LANGUAGES
Language
7.
Excellent
Good
Fair
Poor
PERSON TO BE NOTIFIED IN APPLICANT’S HOME COUNTRY IN CASE OF EMERGENCY
Name:
Address Number:
Street:
City/Town:
Country:
Postcode:
Phone:
Fax:
Email:
Occupation:
Relationship:
8. PREVIOUS IMMIGRATION RECORD TO THAILAND
Date
Purpose of visit
Entry:
Return:
9. FINANCIAL RESOURCE
(FOR STUDY AT MAHIDOL UNIVERSITY)
 Yes
Do you get support for scholarship/grant by any organization?
Name of organization:
Country:
Contact person:
Position:
 No
Address:
Phone:
Type of support:
Fax:
 Tuition fees
 Research fees
Email:
 Monthly allowance  Transportation
 Others (please specify detail): ___________________________________________
10. REFERENCE PERSONS
(2 persons)
(1) Name in full & Title:
Position:
Relationship:
Address Number:
Street:
City/Town:
Country:
Postcode:
Phone:
Fax:
Email:
(2) Name in full & Title:
Position:
Relationship:
Address Number:
Street:
City/Town:
Country:
Postcode:
Phone:
Fax:
Email:
11. DECLARATION
I declare that to the best of my knowledge, the information I have supplied in this application and the
documentation supporting it are correct and complete. I acknowledge that the provision of incorrect
information or documentation relating to my application may result in cancellation of any offer of
enrollment by Mahidol University.
Applicant’s signature:
( _______________________________________ )
Applicant’s name (in Roman block capitals)
Date of application: __________________
FACULTY OF DENTISTRY, MAHIDOL UNIVERSITY
DOCUMENTS CHECKLIST FOR APPLICANTS
(please mark  at each item)
I have already attached the following required documents to complete my application:
1. Application Form
2. DDS. Degree Certificate or equivalent (with officially certified English translation)
3. Academic Transcript (with officially certified English translation)
4. Dental practice license (with officially certified English translation)
5. Recent Photos (Passport size)
6. English certificate (TOEFL/ IELTS/MU Test).
7. Curriculum Vitae
8. Statement of Purposes and Career Goals (not more than 1 page)
9. Current Financial Statement / Scholarship Letter
10. Brief Research Proposal (recommended)
11. Recommendation Forms (directly submitted by at least 2 referees)
12. Copy of Passport for foreign applicant.
13. Non-refundable application fee 50 US dollars payable to: Peerapong Santiwong.
13.1 For foreigner: Payment Via “Western Union” Money Transfer (https://wumt.westernunion.com)
Please attach the evidence of money transfer indicating “Code Number “issued by Western Union to us.
13.2 For Thai: (details of bank account will be notified)
Important Note:
1. The admission process will be completed with fill-in application forms of A and C with all required documents as
mentioned in the checklist. Particularly, Form C must be directly submitted by your referees.
2.
Mail completed application forms with all documents to the following address:
Dr. Peerapong Santiwong
Director of Residency Training in Orthodontics
(International Program)
Orthodontic Department
Faculty of Dentistry, Mahidol University
6 Yothi Rd., Rajthevee District
Bangkok 10400, THAILAND
Email: peerapong.san@mahidol.ac.th
FB: Peerapong Santiwong
Tel. 0-2200-7813
Fax. 0-2200-7812
3.
We will contact and send the formal letter of invitation for examination or acceptation together with Form D
(Certificate of Health) to you after your application has been successfully approved to our program.
4.
Your application will be completed and continued once your payment has been officially verified by the bank.
5.
Application with incomplete application form, documents and uncertified certificates may not be considered.