Universitatea de Stat de Medicin i Farmacie

Nicolae Testemianu din Republica Moldova

FORMULAR DE APLICARE
Actele permit admiterea la studii
Prorector
pentru relaii internaionale

Aprob
Rector

Completai toate cmpurile. Dactilografiai sau completai din liste. Imprimai formularul, semnai-l i expediai
copia scanat.

Ctre: Rectorul Universitii de Stat de Medicin i Farmacie

Nicolae Testemianu din Republica Moldova
Domnule Rector,
INTUNERIC
SIMINA
Subsemnatul (a) ______________________________
____________________________________
(numele, conform paaportului)

(prenumele, conform paaportului)

ROMANIA
052615056
cetean al _____________________________,
paaport Nr. ____________________________
(ara)

Rog, s aprobai admiterea n anul I la Universitatea de Stat de Medicin i Farmacie Nicolae

Testemianu din Republica Moldova prin contract.
Medicina
Facultatea ____________________,

Romana
Limba de studii _____________________

(selectai)

(selectai)

Individual
Modul de aplicare: ________________,
________________________________________________
(denumirea companiei. Nu se completeaz n cazul candidailor care aplic individual)

(selectai)

17 ___
04 ______
1992
Data naterii: ___

Feminin
Celibatar(a)
sexul: _________,
starea familiar _______________

(ziua, luna, anul)

(selectai)

(selectai)

Albastri
155
nlimea __________
cm, culoarea ochilor _______________
(selectai)

INTUNERIC ADRIAN
Numele prinilor: tata _____________________________________________________________

INTUNERIC STELUTA-LUMINITA
mama ___________________________________________________________
0405627
14 ___
08 ______
2011
Nr. diplomei de absolvire _________________________,
data eliberrii ___
(ziua, luna, anul)

COLEGIUL SPORTIV "NADIA COMANECI"

Eliberat de ______________________________________________________________________

strada PAJURA , nr 1 , bl 1 , sc A , ap 4 , etaj 1 , localitatea ONESTI , judetul BACAU

Adresa permanent: _______________________________________________________________

________________________________________________________________________________
________________________________________________________________________________
simina.intuneric@yahoo.com
0741696995
Tel. ______________________________,
email ________________________________________
0741696995
Skype _____________________________________, Viber _______________________________

Da
Solicit cazarea n cmin ___________
(selectai)

M oblig s respect legislaia Republicii Moldova, regulamentele universitare i normele sociale. Declar c
informaiile furnizate sunt complete i corecte n fiecare detaliu.
25 ___
07 ______
2016
Data ___
(ziua, luna, anul)

Semntura Candidatului __________________