• UHS
    UHS


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    ប្រព័ន្ធគ្រប់គ្រងព័ត៌មាននិស្សិត


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Registration Form for Master of Life Sciences and Health - International Track - Infectiology Academic year 2019-2020


Click one Checkbox below for Local or International Student Form




ចំណាំ (Note):

1. សញ្ញា [*] ព័ត៌មានចាំបាច់ត្រូវបញ្ជូល (The asterisk [*] indicated for the required field)​​។

2. សូមចុច [Save as Draft]​ សម្រាប់រក្សាទុកបណ្ដោះអាសន្ន (You must click [Save as Draft] in each tab) ។


ជំនាញភាសាអង់គ្លេស(English Skills)
សូមបំពេញកម្រិតសមត្ថភាពភាសាអង់គ្លេសណាមួយខាងក្រោម (Please fill in your English Proficiency level at least one)៖
ស្តាប់(Listening)*
អាន(Reading)*
សរសេរ(Writing)*
និយាយ(Speaking)*
ពិន្ទុសរុប (Overal Band Score)*
IELTS
TOEFL
Other

ភាសាផ្សេងៗ(Other Languages)
ភាសា(Language) កម្រិត(Level) Action

ជំនាញប្រើបាស់កុំព្យូទ័រ(Computer Skills)
សូមរៀបរាប់(Description)

ចំណាប់អារម្មណ៍និងចំណង់ចំណូលចិត្ត(Interests and Hobbies)
សូមរៀបរាប់(Description)




ស្នាដៃ និងប្រវត្ដិការបោះពុម្ពផ្សាយ (Awards and publications)
ល.រ(No) ប្រភេទស្នាដៃ និងការបោះពុម្ភផ្សាយ(Award and Publication Type) ឆ្នាំទទួលបាន(Year Awarded or Published) ចំណងជើង(Publication Title) Link to Publication Action

ព័ត៌មានមូលដ្ឋាន (Basic Information)

នាមត្រកូល (Last Name)*​ :

នាម​ (First Name)* :

នាមត្រកូល​ឡាតាំង (Last Name in Latin)* :

នាម​ឡាតាំង (First Name in Latin)* :

ភេទ (Sex)* :

ថ្ងៃ-ខែ-ឆ្នាំកំណើត (Date of Birth)*:

ទីកន្លែងកំណើត (Place of Birth)* :

ស្ថានភាពគ្រួសារ (Marital Status)* :

ទូរស័ព្ទ (Telephone)* :

+855

អ៊ីម៉ែល (Email)* :

ឯកសារសម្គាល់ខ្លួនយ៉ាងហោចណាស់មួយខាងក្រោម (Identity with any of the following documents)

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name='chkID[]' checked=checked /> លិខិតឆ្លងដែន (ប្រសិនបើមិនមានលិខិតឆ្លងដែន សូមកុំគូសប្រអប់លិខិតឆ្លងដែន ហើយសូមផ្តល់ឯកសារសម្គាល់ខ្លួនជាអត្តសញ្ញាណប័ណ្ណឬសំបុត្របញ្ជាក់កំណើត ឬអាចផ្លល់ទាំងបីឯកសារក៏បាន) (Passport. In case you don't have passport, you have to provide either ID card information or birth certificate or you can provide the three documents). :

ផុតកំណត់របស់លេខលិខិតឆ្លងដែន (Expiry Date of Passport) * :

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id='chkidentity' name='chkID[]' /> លេខអត្ដសញ្ញាណប័ណ្ណ (Identity card) :

ផុតកំណត់របស់អត្ដសញ្ញាណប័ណ្ណ (Expiry Date of Identity Card) :

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id='chkbirth_certificate' name='chkID[]' />លេខសំបុត្រកំណើត (Birth Certificate Number) :

អាសយដ្ឋានបច្ចុប្បន្ន (Current Address)

លេខផ្ទះ (Home) :

លេខផ្លូវ (Street) :

ភូមិ (Village) :

ឃុំ/សង្កាត់ (Commune)* :

ស្រុក/ខណ្ឌ (District)* :

ខេត្ដ/រាជធានី (State/province/city)* :


ប្រទេស (Country)* :

អាសយដ្ឋានអចិន្ត្រៃយ៍ (Permanent Address)

លេខផ្ទះ (Home) :

លេខផ្លូវ (Street) :

ភូមិ (Village) :

ឃុំ/សង្កាត់ (Commune)* :

ស្រុក/ខណ្ឌ (District)* :

ខេត្ដ/រាជធានី (State/province/city)*:


ប្រទេស (Country)*:


ព័ត៌មានទំនាក់ទំនងក្នុងករណីបន្ទាន់នៅប្រទេសកម្ពុជា (Contact information in emergency case in Cambodia)

ឈ្មោះ (Contact Name) *​ :

ត្រូវជាអ្វីនឹងនិស្សិត (Relationship with Student)*​ :

លេខទូរស័ព្ទ (Phone Number)*​ :

អ៊ីម៉ែល (Email)​ :



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អំពីឪពុក (Father’s Information)

នាមត្រកូលឪពុក (Father’s Last Name)*​ :

នាមខ្លួនឪពុក (Father’s First Name)*​ :

ឆ្នាំកំណើត (Year of Birth)*​ :


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ជនជាតិ (Race) :

សញ្ជាតិ (Nationality)*​ :

នៅរស់ (Alive) ឬ ស្លាប់ (Passed Away)*​ :

មុខរបរ (Occupation)*​ :

ទីកន្លែងធ្វើការ (Work Address)*​ :

អ៊ីម៉ែល (Email):

លេខទូរស័ព្ទ (Phone Number)*​ :


អំពីម្ដាយ (Mother’s Information)

នាមត្រកូលម្តាយ (Mother’s Last Name)*​ :

នាមខ្លួនម្តាយ (Mother’s First Name)*​ :

ឆ្នាំកំណើត (Year of Birth)*​ :


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ជនជាតិ (Race)*​ :

សញ្ជាតិ (Nationality)*​ :

នៅរស់ (Alive) ឬ ស្លាប់ (Passed Away)*​ :

មុខរបរ (Occupation)*​ :

ទីកន្លែងធ្វើការ (Work Address)*​ :

អ៊ីម៉ែល (Email)​ :

លេខទូរស័ព្ទ (Phone Number)*​ :


អំពីអាណាព្យាបាល (Legal guardian​​ information):

ឈ្មោះអាណាព្យាបាល (Legal Guardian’s Full Name): *

ត្រូវជាអ្វីនឹងនិស្សិត (Relationship with Student) *​ :

លេខទូរស័ព្ទ (Phone Number) *​ :

អ៊ីម៉ែល (Email) ​ :



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កម្រិតវិទ្យាល័យ (High School Education)

ល.រ(No) កម្រិតសិក្សា (Degree)* ជំនាញ (Major) ក្រសួង ឬស្ថាប័ន (Institution)* ឆ្នាំបញ្ចប់ (Graduated Year)* រាជធានី/ខេត្ត (City/State)* ប្រទេស (Country)* លេខកូដដំបន់ (Zip Code)*
1 High School

កម្រិតឧត្តមសិក្សា (Higher Education)

សូមបំពេញ កម្រិតអប់រំឧត្តមសិក្សា តាមលំដាប់លំដោយតាមឆ្នាំសិក្សា(Higher education background in ascending chronological order)
ល.រ(No) កម្រិតសិក្សា (Degree)* ជំនាញ (Major)* ក្រសួង ឬស្ថាប័ន (Institution)* ឆ្នាំបញ្ចប់ (Graduated Year)* រាជធានី/ខេត្ត (City/State)* ប្រទេស (Country)* លេខកូដដំបន់ (Zip Code)* Action

ព័ត៌មានបណ្តុះបណ្តាលវិជ្ជាជីវៈ (Professional Training information)
ល.រ(No) វគ្គសិក្សា(Course Type) ជំនាញ(Skill) ក្រសួង ឬស្ថាប័ន(Institution) ឆ្នាំបញ្ចប់ (Ended Year) រាជធានី/ខេត្ត (City/State) ប្រទេស (Country) លេខកូដដំបន់ (Zip Code) កែប្រែ(Update)/លុប(Delete)/បិទ(Close)



ព័ត៌មានបទពិសោធន៍ការងារ(Work Experience Information)
សូមបំពេញ ព័ត៌មានបទពិសោធន៍ការងារ តាមលំដាប់លំដោយឆ្នាំ (Work experience in ascending chronological order)

ល.រ(No) ឆ្នាំចូល(Start Year) ឆ្នាំបញ្ចប់(Ended Year) ក្រសួង ឬស្ថាប័ន(Institution) មុខតំណែង(Position) ប្រទេស(Country) Action


ព័ត៌មានការងារស្ម័គ្រចិត្ត(Voluntary Work Information)
សូមបំពេញ ព័ត៌មានការងារស្ម័គ្រចិត្ត តាមលំដាប់លំដោយឆ្នាំ (Voluntary work in ascending chronological order)

ល.រ(No) មុខតំណែង(Position) ទំនួលខុសត្រូវ(Responsibility) រយៈពេល(Duration (Month)) ក្រសួង ឬស្ថាប័ន(Institution) ក្រុង(State/City) ប្រទេស(Country) Action






សូមភ្ជាប់មកជាមួយនូវឯកសារខាងក្រោមនេះ (Please attach the following documents)៖
រាល់ឯកសារនិមួយៗត្រូវមានទំហំតិចជាង ឬ ស្មើ 500 KB(Every document size must be less than or equal to 500 KB)

លេខលិខិតឆ្លងដែន (Passport ID)*​ :


អត្ដសញ្ញាណប័ណ្ណមុខក្រោយ ០១ច្បាប់ (Identity card = 01 set)*​ :


សំបុត្រកំណើត (Birth certificate)*​ :


សញ្ញាបត្រខ្ពស់បំផុតច្បាប់ចម្លងផ្លូវការ ០១ច្បាប់ (Most relevant highest degree legalized by authorities= 01 set) *​ :


ព្រឹត្តប័ត្រពិន្ទុនៃសញ្ញាបត្រខ្ពស់បំផុត ០១ច្បាប់ (Official transcript of the most relevant highest degree = 01 set) *​:


វិញ្ញាបនបត្រភាសាអង់គ្លេសប្រភេទ TOEFL ឬ IELTS ឬផ្សេងពីនេះ ០១ច្បាប់ (Certificate of TOEFL, IELTS or Others if any = 01 set) *​ :


រូបថតទំហំលិខិតឆ្លងដែនថតប្រាំមួយខែចុងក្រោយជាមួយនិងផ្ទៃខាងក្រោយពណ៌ស (Original file 1 file. Passport Photo last six months with white background) *​:


ឯកសារផ្សេងៗ (Other Documents) ​:



































តម្លៃសិក្សាខាងក្រោម មិនគិតពីថ្លៃប្រតិបត្តិការធនាគារ និង ភាពខុសគ្នានៃអត្រាប្តូរប្រាក់
Tuition fee irrespective of bank charge nor exchange rate conversion


ការបង់ថ្លៃជាប្រាក់ធ្វើឡើងដោយផ្ទាល់នៅពេលដែលនិស្សិតមកដល់សាកលវិទ្យាសាល័យវិទ្យាសាស្រ្តសុខាភិបាល ឬ ក៏ចូលគណនីធនាគារខាងក្រោមត្រូវធ្វើឡើងអោយបាន ត្រឹមថ្ងៃទី២១ ខែតុលា ឆ្នាំ២០១៩ វេលាម៉ោង4រសៀល ម៉ោងទីក្រុងភ្នំពេញ

ថ្លៃសិក្សា 2,000 US Dollar ក្នុងមួយឆ្នាំ

The deadline for tuition fee payment either in cash at University of Health Sciences OR to the following bank account is 21st October 2019 (04:00 pm, Phnom Penh Time)

The tuition fee is 2,000 US Dollar per year.

សូមបញ្ជាក់ពីប្រភេទនៃការបង់ប្រាក់ដូចខាងក្រោម (Please confirm your payment method):

Notice: Trying to get property of non-object in E:\xampp\htdocs\sms\admin\modules\admission\online\forms-local\payment.php on line 163
checked required /> ការទូទាត់ជាសាច់ប្រាក់ (On site payment)
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requiredhds /> បង់តាមរយៈធនាគារ​ (Bank transfer)

Name of Beneficiary: UNIVERSITE DES SCIENCES DE LA SANTE

Account number: 300004535166

SWIFT Code: FTCCKHPP

Adress: #73, Preah Monivong Blvd, Sangkat Sras Chak, Khan Doun Penh, Phnom Penh, Cambodia.

សូម UPLOAD ឯកសារបញ្ជាក់ការបង់ប្រាក់តាមធនាគារចូលគណនី ស.វ.ស នៅកន្លែងនេះ
Please upload deposit slip*/money transfer slip* or attach the receipt obtained from the bank once the money has been transferred:




ខ្ញុំបាទ/នាងខ្ញុំសូមសន្យាថាព័ត៌មានដែលផ្តល់ឱ្យក្នុងពាក្យសុំចូលរៀនពិតជាត្រឹមត្រូវទាំងស្រុង។ ក្នុងករណីខ្ញុំបាទ/នាងខ្ញុំ បានផ្តល់នូវព័ត៌មានមិនពិតនិងប្រព្រឹត្តខុសដោយប្រការណាមួយខ្ញុំបាទ/នាងខ្ញុំសូមទទួលខុសត្រូវចំពោះមុខច្បាប់។
I assure that all information in the enrollment application form is completely true. I understand that if false information given, harmful performance and moral misconduct shall be subjected to the rules of law of the country.










ព័ត៌មានអ្នកធានា(Referee Infomation)
ល.រ (No) គោត្តនាម (Last Name)* នាម (First Name)* ស្ថាប័ន (Institution)* សារអេឡិចត្រូនិក (Email) លេខទូរស័ព្ទ (Tel)* ត្រូវជាអ្វីនឹងនិស្សិត (Relationship with student)*
1
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ចាកចេញ ?

តើអ្នកប្រាកដថាចង់ចាកចេញពីប្រពន័្ធ?

សូមចុច ទេ ប្រសិនបើចង់នៅក្នុងប្រពន័្ធ. សូមចុច បាទ/ចាស ដើម្បីចង់ចាកចេញពីប្រពន័្ធ.