Yong Loo Lin School of Medicine

Yong Loo Lin School of Medicine

HARD COPY APPLICATION ONLY

Application Form for Admission in August 2017

Master of Science (Audiology)

Please print or use block capitals throughout this form

Family Name(s): Given Name(s):

(Surname)

______

Office Use Only
Date application rec’d: / /
Date acknowledgement form sent: / / / Form completed:
One passport-size photo:
Declaration signed:
Fees enclosed (where applicable)
Referees Reports (x2)
Educational Certificate(s)/Scrolls
TOEFL/IELTS:
Correspondence:
A) PERSONAL PARTICULARS

NAME (Dr/Mr/Mrs/Mdm/Miss/Ms)*

Surname (Family name): ______
Given Name: ______
Name (as in official document): ______
2. DATE OF BIRTH:______3. PLACE OF BIRTH: ______4. Age: ______
dd/mm/yy)
5. PASSPORT/NRIC NO/FIN:* ______
6. TYPE OF NRIC : [Tick accordingly]
S’pore Pink S’pore Blue FIN Others______(specify)
7. HOME/PERMANENT ADDRESS
______
______
8. MAILING ADDRESS (If different from above)
______
9. Home Tel: ______10. Office Tel: ______11. Mobile Tel: ______
12. EMAILAddress ______13. Fax:______
14. RACE : Chinese/Malay/Indian/Caucasian/Others*______(please specify)
15. GENDER: Female/Male* 16. MARITAL STATUS : Single/Married/Divorced/Widowed*
17. CITIZENSHIP (Non–Singaporean, plindicate whether you are also Singapore PR)
[Tick accordingly]
SingaporeSingapore PRMalaysia Brunei
BangladeshIndiaChinaMyanmar
PakistanPhilippinesIndonesiaSri Lanka
Others______(please specify)
18. NATIONAL SERVICE:Completed / Disrupted /Currently Serving/Exempted/
(delete where applicable and provide additional information as necessary)
______
19. NEXT-OF-KIN
Name (Dr/Mr/Mrs/Miss/Mdm)* ______
Relationship:______Home Tel: ______Mobile Tel:______
Home/Permanent Address: ______
______
* Please delete accordingly
20. LANGUAGES SPOKEN/WRITTEN (Please tick)
Spoken / Written
Excellent / Good / Fair / Poor / Excellent / Good / Fair / Poor
Mandarin
Malay
Tamil
Others (specify)
Others (specify)

B) ACADEMIC BACKGROUND

SECONDARY SCHOOL EDUCATION*

From To Name and Location of School Qualification obtained
______
dd/mm/yy dd/mm/yy
______
dd/mm/yy dd/mm/yy
______
dd/mm/yy dd/mm/yy

TERTIARY EDUCATION/QUALIFICATIONS*

Country of
From To Awarding Institution InstituteQualification obtained*
______
dd/mm/yy dd/mm/yy
Country of
From To Awarding Institution InstituteQualification obtained*
______
dd/mm/yy dd/mm/yy
Country of
From To Awarding Institution InstituteQualification obtained*
______
dd/mm/yy dd/mm/yy
Country of
From To Awarding Institution InstituteQualification obtained*
______
dd/mm/yy dd/mm/yy
Country of
From To Awarding Institution InstituteQualification obtained*
______
dd/mm/yy dd/mm/yy
*IMPORTANT: Please attach certified copies of transcripts for each qualification listed
3. ENGLISH PROFICIENCY TESTS
Applicants whose native tongue or medium of university instruction is not English should submit the Test of English as a Foreign Language (TOEFL) or International English Language Testing System (IELTS) as evidence of their proficiency in the English language
TOEFL Score obtained : ______# Registration Number: ______Registration Date: ______
OR
IELTS score obtained: ______# Registration Number: ______Registration Date: ______
# Please attach certified copies of certificates obtained.
4. ACADEMIC / EMPLOYMENT REFEREES(see Report Forms, PP 9-10)
Names of the TWO referees who are willing to provide reports of your academic/work performance.
Academic:
Name: ______Organisation:______
Employment:
Name: ______Organisation:______
(C) WORK EXPERIENCE (Voluntary and Paid)
Starting with the current occupation:

(D) PREVIOUS APPLICATIONS

Have you ever applied for training inAudiologyelsewhere?

Yes/No IfYES, please state the programmes you applied for and outcome:______
______

Have you previously applied for/been admitted to any other postgraduate coursework program(s)at the National University of Singapore (NUS)?

Yes/No IfYES, please state programme applied for:______
Year of application : ______Outcome of application*: Successful / Unsuccessful
Date of Enrolment : From ______To ______
(dd/mm/yyyy)dd/mm/yyyy)
Current Status*: Graduated/Withdrawn/ Failed/Student/Other

Are you applying for any other postgraduate program at NUS for the coming session?

Yes/No If YES, please state program you are applying for: ______
4. Source of Finance:Company Sponsorship Self-Support Others Specify: ______
Please tick accordingly
5. Are you planning to apply for financial support from a scholarship organization? YES/NO
* Please deleteaccordingly
(E) GOAL STATEMENT (Max 1000 words)
Please attach a statement (using a separate sheet of paper) explaining why you are applying for this MSc (Audiology) Program now. You should include details of any personal or work experiences that are relevant, including research publications or presentations.
(F) OTHER INFORMATION
Have you had or do you have any communicable diseases, mental illness, colour blindness, and/or disabilities (including but not limited to chronic illness, visual or other physical constraints or limitations), which may or may not cause you to require special assistance or facilities while studying at the university?*

Yes No
If "Yes", please provide all relevant information below. This information will allow the University to develop a complete profile of an applicant and to determine whether he/she might need additional resources in his/her studies. The university, however, does not guarantee the provision of special aid (financial or otherwise) to any students.
______
(G) DECLARATION

I declare that the information provided by me in connection with this application is true and complete.
I understand that any inaccurate, incomplete or false information given or omission of material information required shall render this application invalid and NUS may at its discretion withdraw any offer of acceptance made to me on the basis of such information or, if already admitted. I may be liable to disciplinary action, which may result in my explusion from NUS.
I understand that the provision of any inaccurate or false information may render me liable to prosecution in a court of law in Singapore.
I understand that if I have been convicted of a criminal offence by a court of law of any country, I must submit all relevant information together with this application.
I hereby authorized NUS to obtain and verify any part of the information given by me from or with any source, as deems it appropriate.

Have you ever been convicted of any offence by a court of law in any country or are there any court proceedings pending against you any in respect of any offence?

/ ____Yes
____No
If yes, please specify:
2. Are you currently, or have you ever been, charged with or subject to disciplinary action for any type of misconduct, scholastic or otherwise, at any educational institution? / ____ Yes
____No
If yes, please specify:
3. Are you currently, or have you ever been, under investigation or subject to enquiry in respect of any misconduct, scholastic or otherwise, at any educational institution? / _____Yes
_____No
If yes, please specify:
Signed: ______Date: ______
Yong Loo Lin School of Medicine
Division of Graduate Medical Studies /

ACKNOWLEDGMENT FORM

(Please print your name and address below)

Name:
Address:

This Section Is For Official Use Only

Dear Applicant

APPLICATION FOR MASTER OF SCIENCE IN AUDIOLOGY PROGRAMME

This is to acknowledge receipt of your application for the above programme.

Please note that your application is:

complete and will be evaluated in due course.
incomplete and will only be evaluated after the following items that are marked with () are submitted by ______.

Missing Items:

Application Fee of S$20.00 / S$40.00
Certificate & Transcripts of Bachelor’s Degree (Certified True Copies)
Certificate & Transcripts of any other qualifications (Certified True Copies)
Goal Statement
Referee’s Reports (X2)
Certified True Copy of TOEFL/IELTS Scoresheet
OnePassport-size Photograph

We will notify you of the outcome of your application between the months May - Jun.

------

For Director of MSc (Audiology)

ACADEMIC REFEREE’S REPORT

NCE

To the Applicant

Please print TWO copies of this form (pp. 9-10). Complete the first section and then forward the forms to TWO Referees, preferably one academic and one employment related.

IMPORTANT: EACH REPORT MUST BE SEALED ANDSIGNED ACROSS THE SEAL BY THE REFEREE AND RETURNED TO YOU FOR SUBMISSION WITH YOUR APPLICATION PACKAGE.

Name of Applicant ______

[UNDERLINE Surname / Family Name]

Name of Referee ______Position Held______

Name of Institution/Organisation ______

Address of Institution/Organisation______

______

Tel / HP______Fax ______Email ______

To the Referee

The above-named applicant is applying for admission to the National University of Singapore to undertake a two-year intensive course of study leading to a professional practice degree of Master of Science(Audiology) and has given your name as referee. Please complete this form and return it to the applicant in a sealed envelope that has been signed across the seal by you. The applicant will then forward the unopened envelope to the Division of Graduate Medical Studies (DGMS)at NUS along with the supportingmaterials.

Thank you for your time and effort. Please be assured that any information you provide will be treated as confidential. We would appreciate your candid comments.

1. How long have you known the applicant and in what capacity? ______

______

2. What do you consider to be the applicant’s strengths? ______

______

3. What do you consider to be the applicant’s weaknesses?______

______

4. How would you rate the applicant’s ability in an intensive graduate professional course of study at NUS?

______

5. Please rank the applicant in the areas indicated below. We are interested in your comparison of the applicant with his/her peers/colleagues atthe same level. (Please tick)

Below / Above Average / Good / Excellent / Superior
Average / (top 50%) / (top 25%) / (top 10%) / (top 3%)
A. / Intellectual ability /  /  /  /  / 
B. / Professional integrity /  /  /  /  / 
C. / Commitment to public service /  /  /  /  / 
D. / Teamwork /  /  /  /  / 
E. / Quality of oral expression (English) /  /  /  /  / 
F. / Quality of written expression (English) /  /  /  /  / 

6. Please make any additional comments about the applicant’s potential or personal qualities which you feel would be helpful to theAdmissions Committee. We are especially interested in anything you might add that would not otherwise be apparent in the applicant’srecord (e.g. evidence of character, values, a point of interest or concern about which the applicant is particularly enthusiastic, any specialtalent or quality he or she possesses).

______

Signature of Referee Date

Yong Loo Lin School of Medicine
Division of Graduate Medical Studies

APPLICATION FEE FORM

For the Master of Science (Audiology) Programme

INSTRUCTIONS

The following non-refundable application fee (where applicable) is payable when you apply for the

Master of Science in Audiologyprogramme:

Mode of Application / Application Fee
Online application / S$20.00 (inclusive of prevailing GST)
Hard Copy application / S$40.00 (inclusive of prevailing GST)

Payment by Post

-By cheque or bank draft made payable to ‘National University of Singapore’.

-Please write your name, contact number and the programme applied for at the back of the cheque. All cheques have to be valid for at least 3 months upon receipt by the school.

Payment by Cash

Payment by cash will only beaccepted at the Division of Graduate Medical Studies between9.00 am –
5.00 pm from Monday to Friday (Closed on Sat, Sun & P.H).

To be completed by Applicant:

Name of Applicant:
Telephone Number (Office): / Telephone Number (Home):
Mobile Number : / Signature:

FOR OFFICIAL USE ONLY

1.SERIAL NO.: ______2.DATE RECEIVED: ______
3.FORM RECEIVED BY: ______4.CASH/CHEQUE/DRAFT NO.: ______
5.FEE PAID: S$______6.OFFICIAL RECEIPT NO.: ______
7.DATA ENTERED BY: ______8.DATA ENTERED ON (DATE): ______
REMARKS (If any):
Please credit to GL 530132, WBS N-190-000-009-001______
______
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