ApplicationForm 2016/17

Erasmus+ Radiography/Radiotherapy

Please TYPE when completingthis form.

a)Beforecompletingthisform,applicantsmustasktheirhomeuniversitytonominatethemtothe University of Suffolk.Nominationsshouldbesenttothe Erasmus Coordinator, Mr John Morris at:

b)Emailthe following scanned documentstotheErasmus Coordinator:

1. Completed application form

2. Scanned personal details page of passport

3. Official transcript of academic results

4. Police check document

5. Occupational Health Questionnaire

c)Application deadlines are: 31stOctober 2016 for January 2017 entry.

C / ACADEMIC BACKGROUND
Name of College/University you are currently attending:
Title of your current programme of study (degree title):
Name of your Faculty/Department/Course Erasmus Co-ordinator:
E-mail: Tel: Fax:
Name of your Institutional Erasmus Co-ordinator:
E-mail: Tel: Fax:
Please list any class(es) that you are/will be enrolled in that is/are not shown on your transcript at the timeof application:
TITLE: GRADES: / CREDITS:
D / MODULE SELECTION
All students undertaking Erasmus within Radiography/Radiotherapy will study the Independent Negotiated Study module which is 20 ECTS.
Module
Code: / Module Title: / Credits (ECTS)
B822BSC/ORT / Independent Negotiated Study Module / 20
E / LEVELOF ENGLISH (delete as appropriate)
Level of spoken English: Basic Intermediate Fluent
Level of writtenEnglish: Basic Intermediate Fluent
F / DISABILITY OR SPECIFIC LEARNING DIFFICULTY/DIFFERENCE (INCLUDING DYSLEXIA)
Please give details of any learning support needs, including any disability, medical condition and mental health issue for which you require specificsupport.
G / CRIMINAL CONVICTIONS
Do you have any criminal convictions? Yes No (If ‘yes’ please specify)
H / ACCOMMODATION
Accommodation will be arranged for you by UCS during your stay in Ipswich and during your placement.
I / Checklist
Send:
1)This application form
2)Scan of your passport personal details page
3)Official transcript of your academic results so far
4)A Police Check document (to prove you have no criminal record)
5)Complete the on-line Occupational Health Questionnaire
J / DECLARATION BY APPLICANT
I declare that the informationI have provided is correct and complete to the best of my knowledge.
Signature Date

The University works within the BritishData ProtectionAct 1998. The personal data which you provide on this form will be used to administer your applicationand, if you are successful, the arrangements for your participa- tionin the programme. As part of this, data may be passed to your supportingorganisationin your home coun- try. By signing this form you will be giving consent to such uses and transfer of your data. If you have any queries about data use contact the Suffolk Erasmus Coordinator.

K / DECLARATION BY ERASMUS COORDINATOR AT HOME UNIVERSITY
I confirmthat this student has been selected to study at the University of Suffolkunder the Erasmus+ exchange agreement.
Signature Date