FACULTY OF GRADUATE STUDIES, MAHIDOL UNIVERSITY
Phuttamonthon 4 Road, Salaya, Phuttamonthon, Nakhon Pathom 73170, THAILAND
Phone: +66 (0) 2441 9129, (0) 2441 4125 ext 208-210, Fax: +66 (0) 2441 9129
Email: gradinter@mahidol.ac.th; URL : http://www.grad.mahidol.ac.th
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
 Graduate Diploma
 Higher Graduate Diploma
 Master’s degree
 Doctorate degree
< available at http://www.grad.mahidol.ac.th/grad/curriculum/index_en.php
Program Code
Program Name
Paste a passport
photo taken within
the previous 6
months.
Faculty/ Institute
 First semester
 Second semester
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 :
Your present status and the name of the university attended or employer:___________________________
Address in Home Country:
Number and Street:
City/Town:
Country:
Postcode:
Phone:
Fax:
Email:
Correspondence Address: (if different from address in home country)
Number and Street:
City/Town:
Country:
Postcode:
Phone:
Mobile:
Fax:
1
3. EDUCATIONAL BACKGROUND
Educational level
Undergraduate Level
Graduate Level
Year and
Month of
Entrance and
Completion
Name and address of Institution
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?
5.2. Is English the main language spoken in your home?
5.3. Were your studies at university conducted in English?
5.4. Have you taken an English proficiency test in the last 2 years?




Yes
Yes
Yes
Yes




No
No
No
No
Name of the test*
Test Date
Earned Score:
* Please add certificate of English profiency test
6. PROFICIENCY OF OTHER LANGUAGES
Language
Excellent
Good
Fair
Poor
2
7.
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
From
To
9. FINANCIAL RESOURCE
Do you get support for scholarship/grant by any organization?
Name of organization:
 Yes
Country:
Contact person:
Position:
 No
Address:
Phone:
Fax:
Email:
 Tuition fees
 Research fees
 Monthly allowance  Transportation
 Others (please specify detail): ___________________________________________
Type of support:
10. REFERENCE PERSONS
Name in full & Title:
Position:
Relationship:
Address Number:
Street:
City/Town:
Country:
Postcode:
Phone:
Fax:
Email:
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: __________________
3
DOCUMENTS CHECKLIST FOR APPLICANTS
(please mark  at each item)
I have already attached the following required documents to complete my application:
 Completed Application Forms: comprised with
Form A : Application Form
Form B : Background and Proposed Field of Study
Form C : Recommendation Forms (directly submitted by at least 2 referees)
 Two copies of Degree Certificate (with officially certified English translation)
 Two copies of Academic Transcript (with officially certified English translation)
 Two copies of Recent Photos (4.5cm x 3.5cm)
 Two copies of Passport
 Two copies of TOEFL or IELTS
 Two copies of Curriculum Vitae
 Two copies of other documents, which may be requested by each program (such as letter of work experience /
professional license / concept paper)
Important Note:
1. The admission process will be completed with fill-in application forms of A, B and C with all required documents as
mentioned in the checklist. Particularly, Form C must be directly submitted by your referees.
2.
There are two choices to submit your application documents:
 Email completed application forms with all documents to gradinter@mahidol.ac.th (.PDF format are preferred)
 Mail completed application forms with all documents to the following address:
Students Admission Section,
Faculty of Graduate Studies, Mahidol University,
Phuttamonthon 4 Road, Salaya, Phuttamonthon,
Nakhon Pathom, 73170, THAILAND
3.
We will contact and send the formal letter of acceptation together with Form D (Certificate of Health) to you after your
application was successfully approved to our program.
4.
To complete the application, the non-refundable application fee of 500.00 THB must be paid through credit card:
 Visa
 Master Card
4