APPLICATION FORM FOR ADMISSION TO A FULL-TIME UNDERGRADUATE COURSE

FOR USE BY INTERNATIONAL STUDENTS ONLY

Please complete in BLOCK CAPITALS using black ink and referring to the notes on the back page.

QUB SCHOOL
NAME OF QUB COURSE
(please list in order of preference) / 1.
2.
3.
UCAS NUMBER
(if applicable – see note 2)
FAMILY NAME : / GIVEN NAME(S) :
TITLE (MR/MISS/MS/MRS) : / GENDER: (M/F) / PREVIOUS FAMILY NAME :
CORRESPONDENCE ADDRESS : / HOME ADDRESS (IF DIFFERENT) :
POSTCODE: / POSTCODE:
TELEPHONE NUMBER : / TELEPHONE NUMBER :
E-MAIL : / MOBILE TELEPHONE NUMBER:
DATE OF BIRTH : / COUNTRY OF BIRTH :
NATIONALITY : / COUNTRY OF DOMICILE :
PASSPORT NUMBER : / DATE OF EXPIRY :
HAVE YOU EVER HELD A TIER 4 (GENERAL STUDENT) VISA FOR STUDY IN THE UK? / YES c ___/___/____ NO c
DD/MM/YYYY
(Give date of visa expiry and attach a scanned copy to this form)
IF YOU ARE, OR HAVE BEEN, A STUDENT AT THIS UNIVERSITY, PLEASE STATE, IF POSSIBLE, YOUR STUDENT NUMBER : / ______
IF YOU ARE MAKING THIS APPLICATION WITH THE
ASSISTANCE OF AN AGENT OR EDUCATION ADVISER,
PLEASE GIVE THE AGENT’S NAME AND DETAILS / COMPANY NAME: ______
CITY/COUNTRY: ______
EMAIL:

ENGLISH LANGUAGE QUALIFICATIONS

Please provide details and enclose scanned copy of certificate(s)

NAME OF TEST
(eg. IELTS, TOEFL ibt, O-Level) / RESULT/GRADE
(include component results if appropriate) / DATE OBTAINED/
TO BE TAKEN
OFFICE USE ONLY
DATE / DECISION (and conditions if any) / DATE OF RECEIPT


SCHOOL/COLLEGE EDUCATION

ATTENDANCE AND EXAMINATIONS AT SCHOOL/COLLEGE

NAME OF SCHOOL/COLLEGE
DATES (mm/yy-mm/yy)

SCHOOL/COLLEGE EXAMINATIONS (eg. IGCSEs, A-Levels, Edexcel, SPM, O-levels, IB, High School Diploma or

equivalent)

INCLUDE DETAILS OF EXAMINATIONS STILL TO BE TAKEN

TITLE OF
EXAM
(eg A-level) / DATE
TAKEN
(mm/yy) / SUBJECT AND
LEVEL
(if appropriate) / RESULT
OR
GRADE / TITLE OF
EXAM
(eg A-level) / DATE
TAKEN
(mm/yy) / SUBJECT AND
LEVEL
(if appropriate) / RESULT
OR
GRADE

NOTE: AN OFFICIAL TRANSCRIPT OF THE SCHOOL COURSES YOU HAVE COMPLETED, SHOWING THE GRADES OBTAINED, MUST BE INCLUDED WITH THIS APPLICATION. IF NECESSARY, INCLUDE AN OFFICIAL TRANSLATION INTO ENGLISH.

HIGHER EDUCATION

ATTENDANCE AND EXAMINATIONS AT THIS AND OTHER UNIVERSITIES

UNIVERSITY/COLLEGE
DATES (mm/yy-mm/yy)
DEGREE SUBJECT
SUBJECT / YEAR / RESULT / SUBJECT / YEAR / RESULT

NOTE: AN OFFICIAL TRANSCRIPT OF THE UNIVERSITY COURSES YOU HAVE COMPLETED, SHOWING THE GRADES OBTAINED, MUST BE INCLUDED WITH THIS APPLICATION. IF NECESSARY, INCLUDE AN OFFICIAL TRANSLATION INTO IN ENGLISH.


REFEREES

Please either include references with your application form, or provide details of your referees below

Give names and addresses of two referees, who should be associated with your school, university, college or professional institution, and should be familiar with your academic or professional work.
NAME : / POSITION :
ADDRESS :
POSTCODE:
PHONE: / EMAIL:
NAME : / POSITION :
ADDRESS :
POSTCODE:
PHONE: / EMAIL:

OTHER INFORMATION, INCLUDING ANY RELEVANT PROFESSIONAL OR BUSINESS EXPERIENCE

Please provide any other information that you wish to be taken into account in support of your application (use continuation sheets if necessary).

DISABILITY/SPECIAL NEEDS (Please refer to notes below)

DO YOU HAVE ANY DISABILITY OR SPECIAL NEEDS?
If the answer is NO please use code A in the box provided.
If the answer is YES please use the appropriate code (see below) and give a brief description of your disability. / c

The University’s policy is to view applications from disabled students on the same academic grounds as those applied to all candidates. It is essential, however, for the University to know about the degree of disability or special need in advance so that it may offer advice on what facilities – or special treatment where necessary – may be available. Potential applicants who have a serious disability or special need are advised to contact Disability Services (tel: +44 (0) 28 9097 2727) as soon as possible regarding their disability.

DISABILITY / SPECIAL NEEDS CODES
A / No disability
B / You have a social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder
C / You are blind or have a serious visual impairment uncorrected by glasses
D / You are deaf or have a serious hearing impairment
E / You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy
F / You have a mental health condition, such as depression, schizophrenia or anxiety disorder
G / You have a specific learning difficulty such as dyslexia, dyspraxia or AD(H)D
H / You have physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
I / You have a disability, impairment or medical condition that is not listed above
J / You have two or more impairments and/or disabling medical conditions


CRIMINAL CONVICTIONS – see Note 6 below

DO YOU HAVE ANY CRIMINAL CONVICTIONS?
Please refer to the notes below. If you do not tick either the ‘Yes’ or ‘No’ box, we will return your form for completion. This will delay consideration of your application. / Yes / c / No / c
DECLARATION
I confirm that the information given on this form is true, complete and accurate and no information requested or other relevant information has been omitted. I accept that if any information is inaccurate or has been omitted, the University reserves the right to cancel my application and I shall have no claim against the University in relation thereto.
If offered a place in due course I understand that, in accepting, I agree to abide by the rules and regulations of the University. By signing the application form I confirm my agreement to this.
I consent to the University processing the information in this form for administrative purposes, including consideration of my application in accordance with the provisions of the Data Protection Act.
SIGNATURE ………………………………………………………………. DATE …………………………………………….

NOTES

1 This form is to be used by international applicants who wish to apply directly, and only, to Queen’s or who have been asked to provide information in advance of submitting a formal UCAS application. It should be returned to the Admissions and Access Service, Lanyon Building North, Queen’s University Belfast, Belfast, BT7 1NN as soon as possible. Applications may be scanned and emailed to

2 If you have already submitted a UCAS application in the current admissions cycle (for entry either to Queen’s University Belfast or another institution), the UCAS number MUST be included in the appropriate box on page 1 of the form. If you subsequently submit a UCAS application you must include Queen’s as one of your choices and advise us of your UCAS personal ID as soon as it is known.

3 The application may be accompanied by a covering letter, if appropriate. To expedite your application, please include official transcripts of your academic background to date, including high school certificates, English language qualifications, and transcripts of university study if applicable. If necessary, please send official translations into English. Documents may be scanned and emailed to

4 Before completing the form, applicants should acquaint themselves with the requirements for entry to the course, and with the regulations of the School at http://www.qub.ac.uk/home/StudyatQueens/InternationalStudents/

5 International (non-EU) students are required to produce evidence that they have made adequate financial provision for their maintenance and payment of fees. Enrolment may not take place until fees have been paid

6 CRIMINAL CONVICTIONS

You are requested to state whether or not you have any relevant criminal convictions except a motoring offence for which you have received a fine or three penalty points or a spent sentence (as defined by the Rehabilitation of Offenders Act 1974 / Rehabilitation of Offenders (NI) Order 1978), except for certain courses (see below).

‘Relevant criminal convictions’ are defined as criminal offences involving any kind of violence, including threatening behaviour, offences concerning the intention to harm or resulting in actual bodily harm; the unlawful supply of controlled drugs or substances where the conviction concerns commercial drug dealing or trafficking, offences involving firearms, arson, or those listed in the Sexual Offences Act 2003 / Sexual Offences (NI) Order 2008 or the Terrorism Act 2006 / Terrorism (NI) Act 2006. Criminal offences include convictions, cautions, admonitions, reprimands, final warnings, bind over orders or similar.

Certain professions or occupations, particularly teaching, medicine, dentistry, law, accountancy, actuarial, healthcare, social work, pharmacy and professions or occupations involving work with children or vulnerable adults, including elderly or sick people, are exempt from the Rehabilitation of Offenders Act 1974 / Rehabilitation of Offenders (NI) Order 1978. When applying for any such courses you must tell us about any spent or unspent criminal convictions, including cautions, reprimands, final warnings, bind over orders, penalty notices, ASBOs or violent offender orders.

If you have not been convicted of a criminal offence, you must tick the ‘No’ box. If you tick the ‘Yes’ box the University may ask you to send more details. If your conviction involved an offence similar to those set out above, but was made by a court outside the United Kingdom, you should tick the ‘Yes’ box.

If you do not answer this question we will contact you in writing and this will delay the processing of your application.

If you are not sure whether to tell us about a previous conviction, you can get more advice from a solicitor, but you may have to pay for this.

If you are convicted of a criminal offence after you have applied, you must tell us and provide details.