NO………………
……
Attach a recent
3 cm x 4 cm
photograph
here securely
MAHIDOL UNIVERSITY
FACULTY OF DENTISTRY
APPLICATION FOR ADMISSION
Ph.D. / MASTER DEGREE ACADEMIC 2016
EXCHANGE 1 MONTH ACADEMIC 2015
IDCMR Scholarship
*Complete all sections using BLOCK LETTERS
1. ADMISSION INFORMATION
Doctorate degree in
Master’s degree
 Dental Biomaterials Science
 Master of Science Program in Oral Biology
 Oral Biology
 Master of Science Program in Implant Dentistry
Master of Science Program in Dentistry
 Major in Community Dentistry
 Major in Oral and Maxillofacial Surgery
 Major in Oral and Maxillofacial Radiology
 Major in Maxillofacial Prosthetics
 Major in Prosthodontics
I wish to apply for:
 First Semester
 Second Semester
Academic Year 2016
Exchange Department (1 Month Program)
 Oral and Maxillofacial Surgery
 Oral and Maxillofacial Radiology
 Orthodontics
 Oral Medicine and Periodontology
 Operative Dentistry and Endodontics
 Prosthodontics
 Pediatric Dentistry
 Masticatory Science
 General Dentistry (Undergraduate students could only select this)
I wish to apply for 1 month exchange program:
Between: 1 September – 30 September 2015
2. PERSONAL INFORMATION
Family name
First name
Title
Date of birth
Mr Ms Mrs
Faculty staff
Day Month
 Professor
Year
Dental student
 Postgraduate
 Associate Professor
___ Year
 Assistant Professor
 Undergraduate
 Dr.
___ Year
3. ADRESS IN HOME COUNTRY
Number and Street
City/Town
Telephone
State
Fax
Fax
Country
E-mail
Postcode
4. CITIZENSHIP
Country of Nationality/ Citizenship
Passport number
Expiry date
5. EDUCATION RECORD
Provide details of relevant academic qualifications (undergraduate and postgraduate levels)
Degree
Field
Institution
Year Enrolled
from…to…
Country
6. EMPLOYMENT RECORD
Employer
Period of Employment
from…to…
Position
and Responsibility
Address
(Town, Country)
7. PROFICIENCY IN ENGLISH
Is English your first language?
YES
NO
Is English the main language spoken in your home?
YES
NO
Were your studies at university conducted in English?
YES
NO
Have you taken an English proficiency test in the last 2 years?
NO
YES
Name of Test
Score
8. 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 the Faculty of Dentistry, Mahidol University.
______________________________
Applicant’s Signature
Date_________________________
1. One (1) completed application form
2. Two (2) recent photographs (attached to application form) 3 cm x 4 cm
3. One (1) copies of degree certificate
4. One (1) copies of certified academic transcripts or grade report
5. One (1) copies of statement with study plan and career goals (100-150 words)
6. Two (2) letters of recommendation from university
7. One (1) copies of TOEFL score report of 500 or an IELTS of 6.0 or higher
8. Other evidence required by each program such as letter certifying working experience or a copy of
relevant professional license
Return this form and attachments to:
International Relations Office
Faculty of Dentistry, Mahidol University
6 Yothi Street, Phaya Thai,
Bangkok, THAILAND
Tel: 66 (2) 200 - 7600
Fax: 66 (2) 200 - 7988
E-mail: dtinter@mahidol.ac.th