Imperial College London

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1 APPLICATION FOR ADMISSION AS A VISITING [OCCASIONAL] STUDENT THIS FORM IS ONLY FOR THE USE OF STUDENTS NOT WISHING TO BE AWARDED A QUALIFICATION. FOR THE USE OF EXCHANGE AND OTHER OCCASSIONAL STUDENTS Read carefully the notes provided on pages 4-5 before completing the form Complete the form in black ink ONLY DO NOT WRTIE IN THIS COLUMN REGISTRY USE ONLY Reference Number Date Received Do not write in this column 1.APPLICATION DETAILS Surname or Family Name (BLOCK letters) Title (Mr, Miss etc) Sex (tick box) Male Female All other names (BLOCK letters) Marital status (tick box) Single Married Date of Birth Day Month Year Fee Class STD Type Sponsor Code Country of Birth address Category of Admission sought; See not 1 on page 4 (tick box) If exchange Student give name of home institution: Desired date of Admission Country of Permanent Residence Nationality Occasional Student [NON-EXCHANGE] Exchange Student Proposed duration of studies Country of Birth Domicile Nationality Start Duration Department/Course to which Admission sought Course Special requests regarding programme of study (if any) Dept DO NOT WRITE BELOW THIS LINE CONTINUE ON PAGE 2 For Departmental Use Only : Departmental Decision Departmental Signature Date Accepted for Year of Study (i.e. 1 st, 2 nd etc) Level/Year of study, e.g. MSc Course, 4 th year MEng Accepted Solely for Project Name of Supervisor Non-Exchange Applicants Only: Additional Conditions to Standard College Requirements Not Accepted Notes and Comments

2 Surname or Family Name (BLOCK letters) All other Names (Block Letters) 2. SCHOOL EDUCATION Complete this section School(s) Dates of Attendance Examination(s) taken Subject(s) Mark or from to Grade 3. HIGHER EDUCATION Complete this section College/University Dates of Attendance Examination(s) taken Subject(s) Mark or from to Grade 4.EMPLOYMENT/WORK EXPERIENCE give details of any experience relevant to your application Employer(s) Dates of Employment from to Nature of position/experience

3 Surname or Family Name (BLOCK) letters All other Names (BLOCK) letters 5.ADDRESSES Permanent Home Address Present Address for Correspondence Name and Address of parent(s), guardian(s) or next of kin Address valid until (date): Changes must be notified immediately 6. Financial Support [Payment of Tuition Fees] Student Exchange applicants may leave this section blank Person or organisation accepting responsibility for your fee liability Self Sponsor Not yet known (see below) If sponsored, give name and address of person or organisation to whom tuition fee invoice should be sent If Not yet known, list the person(s) or organisation(s) to whom you have applied for support 7. REFEREE whom you have asked to provide a confidential reference to the College Name of Referee Address of Referee Capacity in which Referee has knowledge of you 8. ADDITIONAL INFORMATION Give here any additional information, not requested elsewhere on this form, which is relevant to your application and which may be of assistance to the College, (e.g. personal or sporting interests, hobbies, non-academic activities, career intentions etc.) 9. PERSONAL RECORD please refer to notes on Page 5 Do you have a criminal conviction? Yes No Disability Code Number (0-8) 10. DECLARATION [Failure to sign the Declaration may delay processing of your application] (a) I certify that the statements made by me on this form are correct (b) I confirm that, if admitted to the College, I will conform to the College Regulations for Students and that I have read the current regulations published on the College Website at (c) I understand that if admitted to the college, and if my funds should at any time during my course prove to be inadequate, the college will not be able to provide financial assistance either by grant or be remission of fees. (d) I authorise the College to permit any thesis, dissertation, essay or project arising from my work at the College to be consulted, borrowed or copied in accordance with College and University of London regulations. (e) I understand my signature below gives the College under the Data Protection Act 1998 to process the information provided, including data of a sensitive nature, for standard university administrative processes that have been notified to the Office of the Information Commissioner Signature of Applicant Date

4 NOTES FOR THE GUIDANCE OF EXCHANGE and NON-EXCHANGE OCCASIONAL APPLICANTS WHEN COMPLETING THE APPLICATION FORM 1. All applicants should complete fully all the sections of this application form. 2. Notes to assist the applicant in completing Section 9 of the Application Form : See Page 5 3. All applicants must enclose with their application form: [Exchange applicants only] a letter from the designated Exchange Programme Co-ordinator at your home university/college nominating you for the exchange with Imperial College. one academic reference/testimony/report from a member of staff at their home university/college who is familiar with your academic studies an official document from your university/institution listing the courses and examinations you have taken to date and plan to take this current academic year a Curriculum Vitae (CV) : must include an address [Non-Exchange applicants only] details of contact (e.g. s/phone calls) already made with Imperial College [Non-Exchange applicants only] details of any English Language Qualifications awarded. Either the learning agreement which your home university/college require you to use OR a provisional list of courses/study plan/project you would like to be considered for. Please note that it is not normally possible to confirm any programme of study until a student - having been admitted - has arrived and registered with the College. 4. Post your complete application as soon as possible to: Adrian Hawksworth Student Placement Office Room 320, Level 3 Sherfield Building Imperial College London London SW7 2AZ UNITED KINGDOM 5. ALL APPLICANTS SHOULD NOTE THE FOLLOWING On receipt of your application by the College: exchange students will be sent an acknowledgement by the Student Placement Office non-exchange occasional applicants will be sent an acknowledgement letter from the College Admissions Office stating a reference number which you should quote in any verbal or written correspondence with Imperial College Your application will be considered by the department in which you wish to study and all decisions will be communicated to you by the College Admissions Office. Failure to complete the application form fully or to provide supporting documentation may delay consideration of your application. If you are sent an official letter of admission you will then receive separately an application form for a room in a College hall of residence (unless, however, your offer letter is dated after 31 st July in which case you should and arrange for the delivery/faxing of the said application form). Enquiries concerning accommodation can in the first instance be addressed to IMPORTANT: Only official exchange/erasmus students admitted to Imperial College for at least a full academic year commencing at the beginning of the academic year (subject to certain conditions) will be guaranteed accommodation during term-time. All other students will be offered assistance in obtaining accommodation. All students admitted to start their studies at Imperial College at the beginning of the academic year will receive up to date information [Student Handbook] during the summer. Students admitted to start their studies at other times can obtain orientation advice from Any queries by page 4 Admissions Office, Imperial College London, January 2006

5 NOTES FOR THE GUIDANCE OF EXCHANGE and NON-EXCHANGE OCCASIONAL APPLICANTS WHEN COMPLETING THE APPLICATION FORM Notes to assist the applicant in completing Section 9 of the Application Form Criminal Record If you have a criminal record, you must tick the box provided on the application form. Disability Code The College welcomes applications from people with disabilities and its policy is to view applications from disabled people on the same academic grounds that apply to all applicants. It is helpful for us to be aware at this stage of any likely requirements you may have during your period of study. Please select the most appropriate code from the list below and enter it in the box on the form. 0 None 1 You have a specific learning difficulty (e.g. dyslexia) 2 You are blind or partially sighted 3 You are deaf or hard of hearing 4 You use a wheelchair or have mobility difficulties 5 You have Autistic Spectrum Disorder or Asperger Syndrome 6 You have mental health difficulties 7 You have a disability that cannot be seen, e.g. diabetes, epilepsy or a heart condition 8 You have two or more of the above 9 You have a disability, special need or medical condition that is not listed above Page 5 Admissions Office, Imperial College London, January 2006

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