ERASMUS + PROGRAMME

(INCOMING STUDENT RECORDS FORM)

Please complete this form and enclose a copy of yourTranscript of Studies. Return the documents to Study Abroad Office, International Office, Aberystwyth University, Cledwyn Building, Aberystwyth SY23 3DD, Wales UK.

Email: Tel: +44 (0)1970 622364

FAMILY NAME:
FIRST NAME:
GENDER:
DATE OF BIRTH:dd/mm/yy
NATIONALITY:
NEXT OF KIN: Emergency Contact
NEXT OF KIN: Contact Details / Tel.
HOME UNIVERSITY:
Level Of Current Degree Programme:
UG (Undergraduate)
PG (Postgraduate)

PERMANENT HOME ADDRESS

/

CURRENT ADDRESS (until when?)

STREET
TOWN
POST CODE:
CONTRY:
TELEPHONE NO:
E-MAIL
HOST DEPARTMENT AT
ABERYSTWYTH:
PLEASE INDICATE PERIOD OF STUDY/TRAINEESHIP: / Semester 1: 25/09/2018- 23/01/2019
 Semester 2: 24/01/2018 – 02/06/2019
 Whole academic year:(25/09/2018- 02/06/2019)
Disability / Medical Conditions/Additional Requirements:

Do you have a disability/ special needs? YesNo

If Yes, please provide further details:
Criminal Convictions:
If you have any relevant criminal convictions that are not spent please tick the box, otherwise leave it blank
Ticking the box does not exclude you from the application process. However, the University may have to undertake a risk assessment.

Declaration:

I consent to the University’s use of my personal data, some of it sensitive data, in order that it might fulfill its administrative obligations and in order that my application might be processed.

(See for further details.)

In the event that I register as a student of Aberystwyth University, I hereby undertake to pay, as and when due, all University Fees.

I hereby certify that all of the above information is correct and complete and I wish to apply for admission as a student of the University. I also declare that, if admitted I shall conform to all the Rules and Regulations of Aberystwyth University. I understand that the submission of any misleading information during the admission process could lead to the immediate cancellation of my application and the withdrawal of any offer made.

Signature of Application……………………………………………………………………………. Date…………………………………………

All personal data provided by you will be treated strictly in accordance with Data Protection Act 1998.

DISCLOSURE AGREEMENT

In the event that my family or friends have concerns about me, or that the International Office needs to consult with them on my behalf:

I give permission for the International Office to liaise with the following people on my behalf.

Contact 1 (for example: Mrs Jill Williams, Mother, 0781 5555555)

Contact name: ______Relationship to me:______

Phone: ______

Contact 2

Contact name: ______Relationship to me:______

Phone: ______

Signed …………………………………………………………….. Date: ……………..