FREIE UNIVERSITT BERLIN

Faculty of Veterinary Medicine Postgraduate Studies in International Animal Health Luisenstrasse 56, 10117 Berlin, Germany Tel.49 30 2093 6063 Fax. 49302093 6349

CHIANG MAI UNIVERSITY

Veterinary Public Health Centre for Asia Pacific , P.O. Box 212, Chiang Mai University, Chiang Mai 50202, Thailand Tel.+66 53 948 073 Fax.+ 66 53 948 072

APPLICATION FORM For the Joint Degree Programme of FUB and CMU MASTER OF VETERINARY PUBLIC HEALTH
Please affix your photo

A. Personal History
Title Family Name (as shown in passport) First Name Sedhain Bhattarai Prerana Mr. Mrs. Ms. City and country of birth Nationality Date of Birth Age Marital Status Kathmandu, Nepal Nepalese 24/07/1984 28 Married Home Address : House No. 100, Baidam 6, Pokhara, Kaski, Nepal Postal code: 33700 Sex Male Female Religion Hindu

Work Address : Regional Livestock Training Center (RLTC), Department of Livestock Services (DLS), Matepani 12, Pokhara, Kaski Postal code: 33700 Tel : (Country code/ Area Code/ Number) +977 061 524195 Fax : (Country code/ Area Code/ Number) -

Tel : (Country code/ Area Code/ Number) +977 061 462354 Fax : (Country code/ Area Code/ Number) E-mail address : sprerana27@hotmail.com

Name and address of person to be notified in case of emergency : Mr. Ashesh Bhattarai House no. 100, Baidam 6, Pokhara, Kaski, Nepal Relationship to you : Husband

Tel : +977 9856028812

Fax : -

B. Education Record (please provide proof of your degree)

Institution City/Country Year Attended From To 2003 Qualification Obtained Subject

Institute of Agriculture and Animal Science (IAAS), Rampur Campus

Rampur/ Nepal

2008 Bachelor of Veterinary Science and Animal Husbandry (B.V.Sc.&A.H.)

Veterinary Medicine, Pharmacology, Pathology, Microbiology, Public Health, Epidemiology, Theriogenology

C. Training of study in foreign countries ( in relation to professional interests)

Institution City/Country Period From To Certificate/ Degree Award Field of Study -

D. Employment Record
1) Previous Job Name and Address of Organization Nucleus for Empowerment through Skill Transfer (NEST) Nagdhunga 8, Pokhara, Kaski, Nepal Post Box No.-52 Tel: +977 061 528036 Previous Title/Post and Dates (from/to) Training Officer from Nov 2008 to Feb 2008 Program Coordinator from Feb 2008 to Nov 2010 Description of your previous job The job involved me working as a training officer and then program coordinator of Animal Health and Husbandry Unit. Major responsibilities included Training Need Assessment (TNA), training conduction, supervision, monitoring and evaluation and reporting. Apart from it, organization of free health camps, awareness, and survey also came under my responsibility. The major working field was in the far western region of Nepal (which includes the remotest and least developed districts of Nepal). 2) Present Job of Employment Name : Regional Livestock Training Center (RLTC), Department of Livestock Services (DLS) Address : Matepani 12, Pokhara, Kaski, Nepal Postal Code: 33700 Title of Present Job : Veterinary Officer Date of Taking Up Post : 02/11/2010 Type of Organization : Government / Public Private International Others .

Tel :+977 061 524195 Fax : Description of your present job : My present job is based at Pokhara. I work as a veterinary (training) officer with diverse duties. It

involves me planning trainings for the 16 districts of the Western Development Region of Nepal. These trainings involve entrepreneurs, para veterinarians, and technicians. As a training officer I coordinate, monitor, evaluate and supervise the trainings. Apart from this I get involved in administrative activities, treatment of animals and planning as well.

E. Language Proficiency
1. English Listening Speaking Writing/ Reading excellent excellent excellent good good good fair fair fair

F. Financial Support
The whole expense of the study program comprises of: (a) 10,400 Euro of travelling cost, living cost and accommodation, and (b) 18,000 Euro for the tuition fees. Do you seek scholarships? YES. NO. If no, please provide evidence in G.4

G. Others (please provide the belowed document in separate sheets)

1. 2. 3. 4. 5. The English test result from standard organization equivalent to TOEFL A Letter of Motivation A Letter of Recommendation from your organization or advisor (if available) An evidence of financial support. (if available) Four recent photographs

Date: 06/01/2013

Signature: _________________________