Form No .

________________

-

Photograph

ADMISSION FORM
Health Services Academy
Opposite National Institute of Health (NIH), Chak Shahzad, Islamabad
Tel: 051-9255590-4; Fax: 051-9255591, http://www.hsa.edu.pk/

SEMESTER SRPING / FALL
For the Academic Year 20___________
Please type or print in black ink, and mail your completed application to the Health Services
Academy.
1. PROVINCES CODE (PLEASE ENCIRCLE)
AJK
BLCH
FAT

AZAD JAMMU & KASHMIR
BALOCHISTAN
FED. ADMINS. TRIBE AREA

KPK

KHABER PAKHTOON KHWA

PNJB

PUNJAB

SND(R)

SINDH (RURAL)

SND(U
)

SINDH (URBAN)

Note: The applications are advised to fill the priorities / preferences carefully once filed
priorities / preferences would not be allowed to change / shift under any circumstances
2. Programme of Study: 1. *PhD in Public Health 2.MSPH 3.EMSPH 4. MSc-HEM
5.MS-MEDVC 6. PGD-MEDVC
* Applicants for PhD in Public Health must submit a two - three pager proposal
along with admission form
Priority
Programme of Study

1

(Passport No for foreign students) __________________________________________________________________________________ DOMICILE (PROVINCE): _____________________________ NATIONALITY: ___________________________ PERMANENT ADDRESS: __________________________________________________________________________ __________________________________________________________________________________________________ PHONE NO: ________________________________ (with area code) MOBILE: ___________________________________________ POSTAL ADDRESS: _______________________________________________________________________________ __________________________________________________________________________________________________ PHONE NO: ________________________________ (with area code) MOBILE: ___________________________________________ OFFICE NO: _______________________________ (with area code) FAX NO:_____________________________________ (with area code) EMAIL: __________________________________________________________________________________________ 2 ./MRS. _________________________________________________________________ (as on Matriculation certificate) FATHER’S NAME:_______________________________________________________________________________ SEX: MALE FEMALE DATE OF BIRTH: ________ / ______ / ___________ (as on Matriculation certificate) NIC NO. SECTION 1: PERSONAL INFORMATION FULL NAME: MS./DR.3./MR.

4. however please not that HSA will be testing these skills in its own screening exam and interviews after the first phase is complete. SECTION 2: ADDITIONAL SKILLS Please note that the following questions are NOT part of our selection criteria for the first phase of short-listing. ENGLISH LANGUAGE SKILLS How do you rate your English language skills? POOR FAIR GOOD EXCELLENT GOOD EXCELLENT SPEAKING WRITING COMPUTER SKILLS How do you rate your computer skills? POOR FAIR MICROSOFT WORD MICROSOFT POWER POINT MICROSOFT EXCEL SPSS ANY __________________________________________________________________________________________________ OTHER __________________________________________________________________________________________________ SOFTWARE __________________________________________________________________________________________________ (SPECIFY): __________________________________________________________________________________________________ 3 .

5. SECTION 3: QUALIFICATIONS AND EXPERIENCE ACADEMIC QUALIFICATIONS List all the colleges and universities attended in reverse chronological order. Begin with the most recent university. NAME OF INSTITUTION PLACE. COUNTRY DEGREE RECEIVED DATES ATTENDED FROM MARKS OBTAINED TOTAL MARKS TO PROFESSIONAL EXPERIENCE Please describe briefly the nature of your work and responsibilities. List most recent employment first. NAME OF INSTITUTION MAJOR RESPONSIBILITIES AND ACTIVITIES POSITION DATES EMPLOYED TO FROM 4 .

SECTION 5: SIGNATURE FORM If you are offered admission to the Diploma Course. APPLICANT’S SIGNATURE: ________________________________ ________________________________ DATE: 5 . Describe the kind of training you expect to undertake. how do you plan to pay for it? EMPLOYER:__________________________ SELF: ______________ OTHER IFY):_________________________ (SPEC- I affirm that the information on this application form and any additional material that I submit is complete and accurate to the best of my knowledge. Mention how relevant experiences. such as research in the field of public health. cancellation of registration. TOTAL EXPERIENCE IN PUBLIC HEALTH: YEARS MONTHS SECTION 4: STATEMENT OF PURPOSE Outline your reasons for your interest in the Post-graduate diploma course. and your plans for the future. Please do not exceed the space provided below. will aid you in achieving your study objectives.6. I understand that furnishing false or incomplete information may be cause for denial of admission. or revocation of degree. and explain how your study plan fits in with your previous training and your future goals.