FIJI NATIONAL Vedas FENU University wowwinu.ac.é) ‘STUDENT 10 NUMBER APPLICATION FOR ADMISSION TO POSTGRADUATE PROGRAMME Please complate all the sections Tick boxes where applicable A PERSONAL DETAILS . iz Title: Mr.[¥] Mrs.[_] Miss.["] Ms. First Name: JOAQUIM DE JESUS, Country of Citizenship: Sumame: MENDONCA Place of Birth: Other Names: CUM. Province (Fiji: Father's/Mother's Name; MARIO/DOMINGAS. ‘Tax Identification Number (TIN): Bah Certicte Registration Number: panaportNumbor 00021824 ate of itn: 16/12/1989 (Regeralitonsters Gender: Malo[W] Female tiie 8. _ | PROGRAMME OF STUDY. ve Tem Applied: Semester ["] Trimester [7] ‘As postraduate evel, FNU ofr graduate ceriaes, ostoradle crete ond pstgraduato diplomas ina range of specialisations Cntiateconteaos se oferosto students whose fit agrees ia diferent csc (whereas postgraduate erfictes an potgrauate dlomas tre nthe samo dicpine os the frst dogo) DIPLOMA OF INTERNAL MEDICINE 4. Programme: Majors) (i appicabe): 2, Please tick the Level of Programm 1) Postgraduate Diploma Programme [7] |i) Mesters Programme by Courses 3, Preferred Campus: 4. Please tick the College that offers the programme you are applying for at FRU: College of Agricuture Fisheries and Foresty College of Business, Hospitality and Tourism Studies Collage of Engineering, Science and Technology College of Humanities and Education [7] cote ch Neds, wursing and Heath Soreas 5, Please note thatthe Programm ‘lg into the programme. listed in Section B 2() to 2() above, the application(s) are submited to the College Dean for assessing ‘Tobe recognised asa key of F's seem prosperity.c.__ | ADDRESS) Postal Address: Email Address: (or e-naling ofr ltr ee) Phone Contact: Moola: +97077053762 Resident Address: joaquimmendoncat 888@gmal.com Landine: al ‘BAIRRO-PITE DILITIMOR LESTE Contact Person in case of Emergency Name: LUCIA CASTAO TILMAN Relationship: WIFE Telephone: 487073565363 Residential galRAO-PITE DILL Address: D.__ [FUNDING DETAILS Private i tenow Gl ‘Sponsor's Name (i sponsors 1; MOH,GOV.OF TIMOR LESTE E____ | AGADENIG QUALIFICATIONS ‘SECONDARY QUALIFICATION(S) ATTAINED Last Secondary Schoo Attended: PAULOS IV (PRIVATE SCHOOL) Highest Seoondary Qualification: COMPLETED IN NATURAL SCIENCE. Last Year at School: 2000-2008, ‘Qualification: Year 12 or Equivalent ‘Qualification: Year 13.or Eaulvalent ‘School Name: ‘Schoo! Name: Index Number: Year: Index Number: Year Subject Mark | Subject Mark Total (English + 3 Best) Total (English + 3 Best) E,__ [ACADEMIC QUALIFICATIONS * Contre Tea TERTIARY EDUCATION(S) ATTAINED: Year Qualification Title Institution Yoar stared | coy tied LECENSURE IN GENERAL MEDICINE UNIVERSIDADENASIONALTIMOR LESTE | 2006 2012 (NTL) 7 [EMPLOYMENT EXPERIENGE(6) - Deals ae requed io oss erianion oily n absence f appropiate acai bckarouné Postion ‘Organisation Years [GENERAL PRACTISIONER MOH [2013 UNTIL NOW G.__ | MEDICAL HISTORYISPECIAL NEEDS Pease indicate whether you have any medical condi Certificate and support letter rom Special Schools and v7] Yes No if your answer to G above is Yes: (8) of major iless(es) or any disabities that FNU should be amare of (each medical Peoples Organisations i applicable). No.oT-feove Dot: 14642020 Poe 2013 “Tobe recognised as Kay drverot fis economic prosper,[it [CHECKLIST CONFORMATION (oiear tot) pplication wil not be processed ifthe following photocopied and certified true coples of documents have not been attache Tw] Bh ceriente TH] Posspor Size Photo [Secondary Shoal RESUS) "7) Copy of Bi data page of atepO for Repnetnraton! oar "7 Tentary Guaifcaon Resul(s)fepeleable [Later rom Employer aesoabe) T=) Tax Wertfication NumberTIN) leerFRCA Card | [w] Medical Cerificate and supporter rom SECTION G (F sepa) |.__ [APPLICANT'S DECLARATION | Gectare tothe best of my knowledge that all information supplied with this application form is true and compete in all signicant patovers, tjahorize the Fij Natonal University fo colt fom, and disclose to appropriate third parties such information that it may require fo establish end ssmiater my account with the Unversity. | undertake to comply wih the rues and regulations ofthe Fiji National Univers incuding the Chit Protection Poly, {fully understand that making a false declaration isan offence under the law. plaase chick onthe ink to view ll Fi National Unversity Poicos: ips:www tn. finewlabtusipoisegtns 10/09/2020 bonmervvy JOAQUIM DE JESUS MENDONCA Date: Applicant's Signature: ‘ping your name conser ws signature in form) L._ [COMPLETED APPLICATION FORMS ‘The completed application forms) are tobe emailed tothe em adsress below Email: admission@fnu.ac.} fevNo.67 teunDte: 14042020 ape ot ‘Tobe recognised a ay vero lis ecnomc prosperity