Name of Contact at Health Provider's Office/Facility:

Comment-2:

Additional Notes or Comments:

Medical Condition(s) & Surgeries Type:

Type your paragraph here.

Start Date:

Patient DOB:

Comment:

Group ID # (if applicable) & Phone # *

How Many Exams Have You Taken?

Health Insurance Policy and Info (if applicable):

Providing Facility/Doctor/Vendor Name:

UNITS:

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Provider's Office Contact Information

Is the Student interested in USA High School Evaluation Exam & University Acceptance? *

The ministry provides financial support and scholarships to Libyan students to study abroad, promotes scientific research and development and supports the transfer of technology and knowledge from academia to industry.

DBMS JAVERIANA UNIVERSITY

Student's Registration

2026 Semester (1): Enrollment starts on December 16th, 2025.

End Date:

Special Need Info (if applicable):

Student DOB: *

Additional Space for more Info:

Comment-1

Brief Summary of Student's Motivation to Seek Higher Education:

Exceeding Your Expectations

Insured Person's Last Name:

Providing Facility/Doctor/Vendor NPI:

Where do you reside now?

Related Comment::

Student High School Exam Registration ID# *

Applicant's Contact Information:

Contact Info:

Name of Student's Doctor's Info (Phone # and email):

DEAR STUDENT: PLEASE ENSURE YOU HAVE REGISTERED IN PERSON AT YOUR BOARD OF EDUCATION IN YOUR CITY / TOWN TO OBTAIN YOUR REQUIRED EXAM ID NUMBER

BEFORE TEMPTING TO COMPLEATE THIS ONLINE REGISTRATION FORM. FAILURE TO DO SO WILL RESULT IN MAJOR DELAYS OF YOUR APPLICATION.

Misc: Providing Hospital/Doctor Info.

Name of Contact at Provider's Office/Facility:

Undergraduate or Masters?:

University Campus (Online, city/country):: *

End Date:

Student's Field of Study or Major/Minor:

Email *

Student's Previous Education or Diplomas: *

Type of Exam: *

Graduate Student Exam ID #: *

Would You Like to Take The University Acceptance Exam or English Exam only? *

Start Date:

Name of Person Applying for The Student if other than the student):

Information About Health Services Requested

End Date:

Certified American High School Will Be Listed Soon....

Today's Date:

Student/Insurance Information

End Date:

Start Date:

Exam Type: *

Student Last Name: *

Scholarship Name & ID# :

Requesting Doctor's NPI # or Medical ID:

Student First Name *

Dates of Service, Diagnosis, and Procedure Codes

(Enter all that apply - enter "None" in first line if none apply for that category):

Financial Support or Person Responsible for Payment and Contact Info: *

New Student's Information

Student Health Insurance Name (if no insurance type "None"): *

Comment:

Providing Facility/Doctor/Vendor NPI:

End Date:

Start Date (Semester and Year):