Application for Study Abroad at Queen Mary, University of London

Please read the sections on Applying to Queen Mary and Choosing Courses in the Study Abroad Guide (or on the website) before completing this form. Please complete the form in block capitals and black ink. Application for admission in (tick as appropriate): Autumn semester 2012 Autumn semester 2013 Spring semester 2013 Spring semester 2014 Academic Year 2012/13 Academic Year 2013/14

Personal Details
Title: Family name: Date of Birth (d/m/yr): Country of permanent residence: Permanent home Address (please give dates when this address should be used): Gender: Nationality: Given name(s): [Please list ALL]

Telephone:

Fax:

email:

Address for correspondence (if different please give dates when this address should be used):

Telephone:

Fax:

email:

Disability: All applications are considered on academic merit in accordance with the Colleges commitment to promoting equal opportunities for all applicants. It would assist us in offering you appropriate advice if you would give brief details of any disability or special requirements you have in the space provided below (Please attach supplementary sheets if required): A detailed guide outlining current policy and provision for students with special needs is available from the Disability Coordinator, the Admissions Office or the College Website. Please contact us if you would like a copy. If you would like to discuss your needs before submitting this application, you can talk in confidence to the Disability Coordinator on + 44 (0)20 7882 3132.

Education
Home College: Major: Current Cumulative GPA: Courses you are currently studying:

Previous colleges attended (if any):

Module selections
Autumn semester
Module code Module title Required class?

Spring semester
Module code Module title Required class?

References
Please provide contact details of your referee(s) here. The references can either be enclosed with your application or sent separately.
Name: Address: Name: Address:

Telephone:: email:

Telephone:: email:

Declaration
All applicants must read and sign the following declaration. I certify that the statements made by me on this form are correct. I understand that the College reserves the right to withdraw any offer it may make, should any statement in this application prove to be false. I confirm that, if admitted to the College, I will conform to all College Regulations. I understand that the College reserves the right to withdraw or alter any course at any point before the start of the academic year in which that course is due to be offered. Signature:______________________________________ Date:______________________

Returning your application

If you require any assistance with this form please contact us on +44 (0)20 7882 5074 or email h.gibney@qmul.ac.uk Please send your completed application form with a copy of your transcript(s) and references to: Study Abroad Officer Admissions and Recruitment Office Queen Mary, University of London Mile End Road London E1 4NS