G5 Study Abroad Programmeapplication Form

G5 Study abroad ProgrammeApplication Form

1. Personal details (Please complete in capital letters)

Surname (Family Name) / First Name (Given Name) / Gender
Nationality / Date of Birth / Place of Birth
Home/permanent Address
Correspondence address if different from above
Tel Number / E-mail

2. FAMILY DETAILS

Full name of Father / Employer’s Name and Job Title
Full name of Mother / Employer’s Name and Job Title

3. G5 Programme Details

Proposed University (Please indicate your order of preference amongUniversity of Oxford/University of Cambridge/London School of Economics and Political Sciences (LSE)/University College of London (UCL) /Imperial College London)
1st Choice / 2nd Choice / 3rd Choice / 4th Choice / 5th Choice
Proposed Course (Please select up to 3 choices of courses in order of preference)
1 / 2 / 3
Duration of Stay (Please choose) / 6 months / 1 Year

Acknowledgement Whilst we endeavor to match your preferences we cannot make any guarantees that these will be met. Please indicate below whether you will accept the offer from your next available choiceif you cannot be accepted by a certain university/course or there are no more place available

Yes No

4. Qualifications achieved

Dates attended
From To / Name and address of place of study / Subject Area / Title of Qualification / Grade

5. Qualifications Pending/awaited

Dates attended
From To / Name and address of place of study / Subject Area / Title of Qualification / Grade

6. Emolyment/internship/ Extra curriculum activities history

Dates attended
From To / Employers Name & Address / Position Held / Brief Description of Duties

7. LanguageIf English is not your first language, please provide us with details of your English language qualifications i.e. IELTS If you have alternative evidence, e.g. Have been taught in English, please give details below

Language / Qualification / Results/Level / Date Obtained
8. PERSONAL STATEMENTPlease include any information, which would assist us in considering your application. For example, reason for choosing course/subject, career aspirations etc. Continue on a separate sheet if necessary
9. ANY OTHER SKILLS OR HOBBIES

10. REFERENCE Please attach at least one written reference to this form. A referee must be able to comment on your academic ability and must not be related to you. You should provide full contact details for the referee.

Name / Address / Tel Number / Relationship / E-mail Address

11. DECLARATION

If you have a criminal conviction please indicate below
I declare that the information on this form is correct to the best of my knowledge. I understand that if I have been found to have deliberately and seriously misled the universitiesabout the details on this form I could be asked to withdraw from my course. I agree that I am bound by the terms and conditions of the G5 Programmes and will provide additional application documents and pay the relevant fees before the start of the programmeonce accepting the offer. All rights reserved by the Russell Group Association.
Signed / Date