- / Application form

/
for education in Russian Federation at the expense of the Federal funds
of Russian Federation within the quota

.
, *,
To be completed in block letters in Russian and/or English language
Fields marked with * are obligatory for filling
, -* / Country where the * / Registration number*
application is submitted*
/ Cameroon CMR-6175/17
/ Filled in by representative of Russian / Filled in by an officer of Russian Ministry of education
Federation in foreign country and science
( ) / Line of arrival (source of application form)





_____________________________________________________________________________________
/ Filled in by representative of Russian Federation in foreign country
* / Place of visa receipt*
/ Country / City
/ Filled in by representative of Russian Federation in foreign country

1. , ( )* / 2. (), ( )* / Name
Family name, latin letters (according to passport)* (names), latin letters (according to passport)*

ESSOLA DIEUDONNE
3. , * / 4. (), * /
Family name, Cyrillic Russian transcription* Name, Cyrillic Russian transcription*

/ Filled in by representative of Russian
5. ( ), ( 6.
)* / Fathers name (if available), in Russian
Cyrillic transcription*
/ Filled in by representative of Russian
Federation in foreign country Federation in foreign country
( )* /
Place of birth (according to passport)*
(, ) / (country, city)

NGWATTA
/ Filled in by representative of Russian
Federation in foreign country
7. * / Date of birth* 8. * / Sex*
() /(day-month-year) 26.01.1979 / Male / Female
9. * / Citizenship* 10. / Compatriot

, / If you / Im a compatriot
have many citizenships, specify all 1. , ,
, , , ,
. / Compatriot is a person born in the country or lived there before who has common language, historical,
cultural features either a descendant of those persons
1) / Cameroon 2. ( - ) ,
. / Compatriot abroad is a citizen of the Russian Federation living abroad
2) 3. ,
, , , ,
, ,
3) , : / Compatriot is also a person and/or
his/her descent living abroad who belongs to nations living on historical territory of the Russian Federation who made a choice for religion,
( culture and legislation of the Russian Federation including:

) / , , , ,
I am a person without citizenship ; / a person who had the USSR nationality and/or living in countries-
members of the USSR who got citizenship of one of these countries or became a person without citizenship;
() , , ,
,
. / a Russian Federation/USSR emigrant who had a citizenship and got foreign citizenship or became a person
without citizenship.

11. : / Permanent address:

11.1 / Country 11.2 / 11.3 / / 11.4 / / City
Postcode Region / State / Location Douala
/ Cameroon B.P. 2701 Littoral region
11.5 , , , , / Street, building, flat
PK 17 Industrial Engineering Faculty of University of Douala

12. * / e-mail* 13. ( )* / Mobile (cell) phone number

essola_die@yahoo.com (with country code)* (237) 699994755

14. * / 15. * / Date of issue* 16. * / Valid till*

Passport No* () / (day-month-year) () / (day-month-year) 04.12.2018
0059911 04.12.2013 , 1,5 /
The validity of the passport should not expire earlier than 1,5 years from the date of commencement of
visa validity
 18. / ,
17. () ( * /
, , Name of graduated educational organization or where you are supposed to
)* / Level of education you have got (If graduate*
you do not apply for full term of study, and want to undergo a probation,
please choose the level of education obtained)*

,
/ Choose ONLY one point level that gives you a right to continue
studies in Russia
19. / ,
(, , ; 8-9
* / Location of graduated educational
) / Secondary School Certificate (8-9 study years) organization or where you are supposed to graduate*
(, , ; 10-12
) / Higher Secondary School Certificate (10-12 study years) 19.1 / Country 19.2 / City
(
, ) / Vocational Secondary Certificate / Russia --
(Vocational/Technical School)
/ Bachelor Degree
( 55,5 ) / 19.3 , , , / Street, building
Specialty Degree (Higher education 5-5,5 study years) . 1 2 . 601
/ Master Degree
/ PhD
/ Residency training 20. / Graduating year
/ Postgraduate military course 2015
- / Assistantship-traineeship
21. * / Mode of study* / Full-time / Extramural
22. , * / Level of education that you want to obtain in Russia*
22.1 / Choose ONLY one point 22.2 (
/ Vocational secondary ) / Probation (DO NOT specify if continuing professional education)
education ,
/ Bachelor Degree , , ,
( 10 ) / I do not apply for full term of study,
/ Specialty Degree but I want to undergo a short-term program as part of bachelor, specialist,
/ Master Degree master's, PhD programs (up to 10 months)
/ PhD
/ Residency training / Duration of the program:
/ Postgraduate military course
- ( / months
) / Assistantship-traineeship (specialties in the field of
culture and art) / Semester:
/ Continuing / Autumn
professional education
/ Spring

() / Name of the additional professional education / Summer school
program / Educational year

/ Duration of study:
/ months
/ / /
Semester: Autumn Spring
/ / Educational
Summer school year

23. (, ) ( )* / Educational program (specialty,

profession) DO NOT specify if continuing professional education*
() russia-edu.ru / You can use russia-edu.ru website to find the
code and the full name of the educational program
23.1 / Code 15.06.01 23.2 / Full name / Mechanical Engineering

24. ( , -, ) /
Topic of research (for PhD, assistantship-traineeship, residency training)

,
.
25. (, ), * / Educational organizations*
6 . 2 , . . -.
, , , Specify
all 6 points by priority. Do not choose more than 2 educational organizations from one federal region, Moscow city and Saint-Petersburg city. If you mention only 1 educational
organization and this organization refused to admit you, you will be finally refused to study in the Russian Federation.

1) / Don State Technical University

2) / Southern Federal University

3) - ()/ State Technical University - MADI

4) / Far Eastern Federal University

5) / Samara State Technical Universaty

6) / Vladimir State University

named after Alexander and Nikolay Stoletovs
26. ( ) * / Languages (including native) *

/ / , , /
1)
Russian language Native Fluent Intermediate Beginner Do not speak
/
2)
French
Native
/

Fluent
/
, , /
Intermediate

Beginner
/
3)
English
Native
/

Fluent
/
, , /
Intermediate

Beginner
4)
Native
/

Fluent
/
, , /
Intermediate

Beginner
27. () / Necessity to study at the Foundation course (Preparatory Faculty)
() . 1 .
() .
I need to get admission to the Foundation course (Preparatory Faculty) for the study of Russian language. Period of study 1 year. In that case educational
organization is to be chosen by the Ministry of Education and Science of the Russian Federation
28. / Sport achievements 29.
/ Additional
information about different achievements
1. / Football 1 2 3 2012
/ sport / achievement / year

2.
/ sport / achievement / year

3.
/ sport / achievement / year

30. , 31. * / The place of qualification

* / The type of qualification tests that you have tests passing*
taken in your country to obtain the quota*
/ Embassy of Russian Federation
/ Interview () / The Russian Centre of
/ Competition Science and Culture
/ The competition portfolio / National education
/ Testing authority
( () / ther (specify)______________________
) / Out of competition (providing quotas for the special
achievements in training)
() / Other (specify)__________________________
32. : / I attach the following documents:
* / Passport copy* / (
* / Education certificate copy* , -,
) / Research paper in Russian or English language (for PhD,
( assistantship-traineeship, residency training)
)* / Copy of medical
certificate of overall health condition (DO NOT attach if continuing (
professional education)* , -, ) / List of
publications (for PhD, assistantship-traineeship, residency training)
(
)* / Copies of HIV + AIDS , /
certificates (DO NOT attach if continuing professional education)* Copies of documents which confirm the compatriot status

, (opy of
document with the results of the qualifying tests)
(Copies of documents which confirm the knowledge of the Russian
language)
33. / Additional information
 27.07.2006 152- ,
, , ,
. () (-) ,
, ,
. ,
, ./ According to the Federal law from 27/07/2006 No 152-FZ About personal data I accept the processing in
hardware of personal data provided in the application and documents attached for the purpose of realizing my right to obtain education in the Russian Federation by budgetary
appropriations of federal budget. I am informed and agree to provide my personal data noted in the application and documents attached to the Russian educational organizations for
admission decision. I agree with transborder transmitting of my personal data noted in the application and attached documents via Internet.

() , , ,
.
. / I am informed that according to the Russian Legislation I can be required to make educational
documents equivalence procedure. The equivalence procedure is to be realized in compliance with the determinate order on the Russian Federation territory after admission confirmation
letter of the Ministry of Education and Science of the Russian Federation.
/ Date / Signature
() / (day-month-year)

, /
Information representative of the Russian Federation in foreign country who verified the completeness and accuracy of this application form
/ Filled in by representative of Russian Federation in foreign country
/ Officers Position / / Date / Signature
Full name () /
(day-month-year)