The Language Centre,

University College Cork

STUDY / WORK
PROGRAMME
2013/2014
REGI STRATI ON FORM
Personal Details

First Name(s): ________________________________________

Family Name: ________________________________________

Address for Correspondence:






Home Address (if not the same as above address):




________________________________________________________________________________

Date of Birth: _____/_____/_____ Telephone No: _________________________

Male or Female. _____________________ Nationality: ___________________________

First Language: ______________________ Second Language ______________________

Mobile. No. ___________________________ E-mail: _______________________________

Do we have your permission to use your e-mail and/or mobile no. for publicity in the future: Yes/No (please circle one)

Course Start Date: __________________ [Monday]

Host family Request
Yes No
Start Date ______________________ Depart Date ______________________ No. Weeks ______




Registration Form must
be accompanied by
two passport size
PHOTOGRAPHS for a
Student ID Card and file.

Scanned photos will not be
accepted.
Level of English (please circle one):
Elementary Lower Intermediate Intermediate
Upper Intermediate Advanced Proficiency

Please summarise in no more than 20 words your main needs in English:

Where did you hear/read about this course:
________________________________________
Agent Agent Name _______________________
Your university Name of University __________________________
Web Site
Other student
Please give details e.g. name of website: ____________________________________________

REGISTRATION CHECKLIST
1. Send completed Application Form + Educational History + Proof of current English level
e.g. IELTS result, Cambridge Certificate, OR, complete the attached composition.
2. Attach two passport size photographs.
3 Full fees must be paid in advance of course start date (if your Application is approved).
[please email info@langcent.ucc.ie when you have paid Fees]
4. A deposit (non-refundable) of 250.00 must be paid when an offer of a place is made.
Fees can be paid by (international) bank draft drawn on a Irish bank and made payable to
Language Centre, UCC or by lodging monies directly into the Language Centre UCC account
(details below) or by credit/debit card (e-mail info@langcent.ucc.ie for details).
We do not accept personal cheques as payment.
Places will be allocated on a first-come first-served basis.
Minimum numbers are required to form a class, if minimum numbers are not met we reserve
the right to transfer students to a combination of other classes suited to their level, if it is
possible, otherwise a refund will issue.
Bank Details:
Bank Name: Bank of Ireland, 32 South Mall, Cork, Ireland
Account Name: UCC Language Centre
Account Number: 87099989
Sort Code: 90-27-68
IBAN Number: IE58 BOFI 9027 6887 0999 89
Bank Identifier Code: BOFIIE2D All bank charges to be paid by
student.
Completed Application Forms should be returned to:
The Language Centre (English as a Foreign Language), ORahilly Building, University
College Cork, Cork, Ireland. Please mark envelope Intensive Programme.
If you have a query on your application, please send an e-mail to: info@langcent.ucc.ie.
Tel: +353 21 4902043 or 4902898 Web: www.ucc.ie/esol
For Office Use Only
Amount Received: ________ Receipt number: _____________ Date: _____________

Amount Received: ________ Receipt number: ______________ Date: _____________

Total Cost of Course: 5,000
Date acknowledgement letter sent:
__________________________________________________

Date Acceptance details sent to student:
_______________________________________________
Comments:
____________________________________________________________________