Application for Student Admission

to the

American University of Sovereign Nations (AUSN)

AUSN has adopted a racially nondiscriminatory policy as to student admissions, student scholarships, academic degree programs, and educational certificate programs.

(Please download this form and complete it in Word; you can add supplemental pages)

Given Names: Family Name:Sex: Male Female Marital Status:

Please indicate which Master’s degree or Certificate Program you are Applying for:

Master Degree Programs

Master in Public Health (MPH) with emphasis in Healthcare Management (On-site) Master in Public Health (MPH) with emphasis in Healthcare Management (Combination) Master in Bioethics and Global Public Health (MBGPH) (On-site) Master in Bioethics and Global Public Health (MBGPH) (Combination) Master in Healthcare Administration (MHA) (On-site) Master in Business Administration (MBA) with emphasis in Healthcare Management (On-site)

Certificate Programs (All Combination with on-site and on-line instruction)

Certificate in Public Health (MPH) with emphasis in Healthcare Management; Certificate in Bioethics and Global Public Health (MBGPH); Certificate in Healthcare Administration (MHA); and Certificate in Business Administration (MBA) with emphasis in Healthcare Management. Certificate in Community and Peace

Please indicate if you are affiliated to any of the collaborating Institutions of AUSN, and if so, what is your past and current affiliation:

Ethnicities:Date of Birth (Day/month/year):

Place of Birth: Present Nationalities:

Permanent Address:

Tel.:E-mail:Skype:

Present Address:

Cell Tel:Home Tel:

In case of emergency, notify:Name:Address:

Tel: Email:Knowledge of Languages:

Read Write SpeakLanguage Easily Not easily Easily Not

easilyEasily Not

easily

EnglishOther:List all others…

Computer Skills:MS-Word Yes NoMS-Excel Yes NoMS-PowerPoint Yes NoWebsite Design Yes NoGraphic Design Yes NoMultimedia Design Yes NoDatabase Design Yes NoOther (Please specify):Other Skills and Knowledge (Please add comments):Social Research Yes NoHuman Rights Yes NoGender Yes NoIndigenous Studies Yes NoPublic Health Yes NoHuman Resource Management Yes NoInformation Technology Yes NoConference Organizing Yes NoPublic Information/Journalism Yes NoSports Yes NoOther (Please specify): Yes No

Why do you want to study at AUSN?

Please write a brief description or outline of the outcomes you would like to accomplish during your Studies.

Career Plans:

Education (Include: High School/ College/ University) Please attach scanned copies of your University transcripts and Degree Certificates with this application. Original certificates MUST be shown to AUSN staff upon enrolment. All documents submitted remain the property of AUSN and will not be returned.

InstitutionName, Place and

Country

Attended from/to

DegreesObtained / Expected

Major Subjects ofStudy

Mo./Yr Mo./Yr

15. Employment: Please describe any previous practical experience you may have had, giving full details of your duties, which may be helpful in the consideration of your Application for Admission.

Other Potentially Relevant Information:a). University scholarships or academic distinctions:b). Publications (if any):c). Professional licenses held:d). Any related test scores:e). Past community service activities:f). Anything else we should be aware ofInsurance: No, I do not have any kind of Medical Insurance. I would if I start as a Student.Yes, I hereby confirm that I hold a health/ accident insurance policy:

Company name: Policy number:

Yes, this insurance is effective in USA

Any general comments or questions:

Please attach a photograph.

I hereby make application for admission to AUSN. I understand that all fees and tuition must be paid in full when due. I understand that all application materials which are sent to AUSN become the property of AUSN and can not be returned. I understand that the Application Fee is non-refundable.*

___________________________Signature Date: ______________

Please send this form and any attachments or additional documentation to

provost@ausn.info

www.ausn.info