AMERICAN NORTHWEST UNIVERSITY Place for passport

Application form
Admission Office Address photo here
2 Dry Creek St.
Belmopan, Belize
(Central America) (4.5 x 3.5 cm)

Program (choose the appropriate)

Six year MD program Four year Medical degree

Personal data

Male__________ Female__________ First Name

Title (Mr/Mrs/Miss/Mrs etc.)__________ _________________________________

Middle name Last name (Family name)

_________________________________ _________________________________
Father’s first name Mother’s first name

_________________________________ _________________________________
Date of birth (day/month/year) Place of birth (country, city)

_________________________________ _____________________
_________________________________
Citizenship

_________________________________

Passport information
Passport Country Passport Number

_________________________________ _________________________________
Date of Issue (day/month/year) Date of expiry (day/month/year)

_________________________________ _________________________________
Issuing Authority

_________________________________

ANU is
... where YOUR future begins!
Contact Information
Permanent Adress in Home Country Correspondence Adress (if different)
Street and no Street and no

_________________________________ _________________________________
City City

_________________________________ _________________________________
Postal/ZIP-code Postal/ZIP-code

_________________________________ _________________________________
Country Country

_________________________________ _________________________________
Telephone (please type only digits) Stationary phone (optionally only)
Mobile/cell phone number Country code/Area code/Number
In Int’l format (+YYYXXXXXXXXX...)

_________________________________ _________________________________

Language Proficiency Information

Please choose the appropriate
English is my first language ______
I attend a high school/pre-medical
medical college in an English-speaking
speaking country prior to admission_____
English is not my first language (you need to submit proof of your proficiency in English, IELTS min
5.5)_____

Financial support
How do you intent do finance your studies? (Personal savings, Private sponsor, KASP etc.)

_____________________________________________________________________________
Please give details of any loans or grants you are applying for or have already secured (optionally
only, max. 100 characters)

ANU is
... where YOUR future begins!
Payment
Deposit $200 ($200 Administrative Processing fee)
Bank draft to:

Declaration
I consent to the collection and processing or relevant personal data by the _____________________.
I understand that the information provided on this form will be held and used for the purpose of
student administration. All information on this
processing my application for study and for student
application and appended thereto is protected by the goverment data protection laws.

I certify that the information I have given on tihis application form is complete and accurate.

I agree to all the above

Signature Date (day/month/year)

_________________________________ _________________________________

1. Please attach the following:

following

 All school transcripts translated into English and stamped by Notary Public
Public;
 All graduate transcripts;
transcripts
 English language Certificate (if applicable);
applicable)
 Four passport page;
page
 Photocopy passport page
page;
 Photocopy of bank statements of sponsor
sponsor;
 Tax return for the last two years of sponsor (if applicable)
applicable);
 Affidavit from sponsor signed by notary public
public;
 One essay question: 500
50 words.

How do you envisage yourself in 6 year’s time?

If you have no official Certification for English language you may be asked to take an examination in
prior to addmision.

If your English is below our requirement you will be asked to take English Lessons during the first year,
at a small extra cost.

ANU is
... where YOUR future begins!