Scribd
Upload
62 views

Indian Institute of Public Health Gandhinagar: (A University Established Under IIPHG Act, 2015 of Gujarat State)

The document is a nomination/application form for the Master of Public Health program at the Indian Institute of Public Health Gandhinagar for the 2020-2022 academic years. The form requests information such as the applicant's name, age, gender, academic background, work experience, academic awards, extracurricular activities and references. It also provides instructions on submitting required documents and payment by the deadline of May 31st, 2020.

Uploaded by

Bhageshwar Chaudhary
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
62 views

Indian Institute of Public Health Gandhinagar: (A University Established Under IIPHG Act, 2015 of Gujarat State)

The document is a nomination/application form for the Master of Public Health program at the Indian Institute of Public Health Gandhinagar for the 2020-2022 academic years. The form requests information such as the applicant's name, age, gender, academic background, work experience, academic awards, extracurricular activities and references. It also provides instructions on submitting required documents and payment by the deadline of May 31st, 2020.

Uploaded by

Bhageshwar Chaudhary
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

INDIAN INSTITUTE OF PUBLIC HEALTH GANDHINAGAR

(A University established under IIPHG Act, 2015 of Gujarat State)


First Public Health University in India

Affix a passport
NOMINATION / APPLICATION FORM
Size photograph
MASTER OF PUBLIC HEALTH
here
2020-22

(To be filled in by the nominee / applicant in capital letters)

NAME & SURNAME:


DATE OF
GENDER: M F AGE: BIRTH: NATIONALITY:

ACADEMIC BACKGROUND
Name Final
of the Subject/ Stream Board/Univ College/Institution Year of Percentage/
Level of academic qualification Degree ersity
of Affiliation Passing Grade/class

Class X N/A

Class XII N/A

Bachelors/Undergraduate Degree

Masters/Post Graduate Degree or


any other equivalent qualification

Any additional
Qualification/Training

PG ENTRANCE
Have you given any PG entrance exam? Yes ☐ No ☐
If answered yes to previous question
o Full name of entrance exam ______________________ o Year of appearance in exam _____________
o State (if specific to any state) ______________________ o Score (percentage/percentile) ____________

WORK EXPERIENCE* (Internship not to be counted in experience)


Total work experience in years: __________________________________________________________

Duration of Employment Name of Organization Designation Roles/Responsibilities

Current

Past

*To be submitted by relevant certificate clearly mentioning the duration of work.


LIST OF RECENT ACADEMIC AWARDS/ ACHIEVEMENTS (Including publications/ presentation)

EXTRA CURRICULAR ACTIVITIES

Do you belong to SC/ST/OBC/PH? : Yes/ No


(If Yes, please specify category ______________________, please attach self-attested copy of the certificate)

ENCLOSURES: (Please do not send any original certificates-they are to be produced only at the
time of personal interview):
Application fee of Rs.500/- (US$10 for international & SAARC candidates) drawn on Indian Institute of Public Health
Gandhinagar to be paid along with the application form. (send your payment Ref. No & Receipt No. on
[email protected])
Necessary copies of all academic statements from class X onwards and PG entrance exam results
Copy of resume/ curriculum vitae
Contact details of three referees: two academic + one professional (if some work experience)
Statement of purpose (This needs to be a 250-500-word summary, written completely by the candidate, stating
professional goals and career plans, including plans and expectations in pursuing MPH Programme)

Payment options: (A/C Holder Name: Indian Institute of Public Health Gandhinagar; Bank Name: HDFC, Bank Ltd.;
Branch Name: Infocity, Gandhinagar, Gujarat, INDIA, A/C No.: 50100157403005, IFSC Code: HDFC0002497,
BIC/Swift Code: HDFCINBBXXX) / demand draft / cheque payable at par at Ahmedabad.

* THE LAST DATE FOR ACCEPTING APPLICATIONS IS 31st May 2020.

Source of information about MPH Course in IIPHG: _________________________________________________

APPLICANT’S ADDRESS
FOR COMMUNICATION:

CITY:
COUNTRY:
PINCODE:
PHONE (Residence):
FAX:
MOBILE:
EMAIL:

Date: Signature

Nomination / Application form with required documents should be posted to:

Assistant Registrar (Academic Programs)


INDIAN INSTITUTE OF PUBLIC HEALTH GANDHINAGAR
University established under IIPHG Act 2015 of Gujarat State
Opposite Air Force Head Quarters, Near Lekawada Bus stop,
Gandhinagar-Chiloda Road, Lekawada, CRPF.P.O, Gandhinagar - 382042, Gujarat, INDIA
Phone No :079-66740700; E-mail: [email protected], [email protected]
URL: www.iiphg.edu.in, www.phfi.org,

You might also like