School of Medicine & Medical Science

SCHOOL OF MEDICINE & MEDICAL SCIENCE

MSc STUDENT APPLICATION FOR REGISTRATION

SECTION 1 :( To be completed by the applicant)

Personal Details:

Title / Last name / First name / Country of Birth / Country of Citizenship
Date of Birth (dd/mm/yyyy) / Gender / Mothers Maiden Name
Permanent Address:
Contact Telephone number:
Email Address:
Address for correspondence
(If different, to above -
please give dates)
First language:
Second language
UCD student number
(If applicable)

Qualifications:

Qualification:
Standard Obtained:
Awarding Institute:
Date of attendance:
Date of Award:

Qualification 2(If applicable):

Qualification:
Standard Obtained:
Awarding Institute:
Date of attendance:
Date of Award:

Proposed degree of study (Full or Part Time):

MScresearch F/T
MScresearch P/T

StStart / Registration Date:

September 2017
January 2018
May 2018
Subject Area of Degree: e.g. Diagnostic imaging; Vascular Biology; Medicine etc.:

Research Proposal:

Title of Project:
Include background to the project and outline the problem to be addressed. Include research hypothesis, overall aims of the project and methodology to be used. Outline the novelty and significance of the work proposed.
If your project involves a clinical trial please include details of the clinical design of the trial and your specific role in the project.

SECTION 2 : (To be completed by the principal supervisor*)

*Please read the accompanying explanatory notes before completing this form

Principal Supervisor and Nominator:

Title: / First name: / Last name:
E-mail :
UCD PERSONEL NUMBER :
No. of full time students under primary supervision at present: / No. student supervised to completion: / Permanent member of UCD academic staff
Yes ⁭ No ⁭
If no, please indicate current status:
*Adjunct: Yes ⁭ No ⁭
Academic Contract: Yes ⁭ No ⁭
Start date/ End Date contract:
______

*If Adjunct Staff; please contact the postgraduate office at for additional form

Co-Supervisor: (if applicable)

Title: / First name: / Last name:
E-mail :
UCD PERSONEL NUMBER :

Other Supervisor: (if applicable)

Title: / First name: / Last name:
E-mail :
UCD PERSONEL NUMBER :

If more than one other supervisor is involved, please duplicate the above fields. Please note that other supervisors are required only where their expertise is required for the student’s research on an ongoing basis.

Nominator: (if different from principal supervisor)

Title: / First name: / Last name:
E-mail :
Address: / I am attaching a letter of nomination
Yes⁭ No ⁭

Doctoral Studies Panel: For guidelines on proposing suitable advisers, please contact

Adviser 2:

Title: / First name: / Last name:
E-mail :

Details of funding for proposed study period:

Please state if these funds are guaranteed or if an application for funds has been made elsewhere

Source
Amount
Period

Is a substantial proportion of the student’s research to be carried out at an institution other than UCD or UCD-affiliated Sites?

YES ⁭NO ⁭

If YES, prior approval of the College Graduate School must be sought – Please attach supporting documentation

DECLARATION BY PRINCIPAL SUPERVISOR:

NOTE: Emails from the named individuals are acceptable in the place of signatures – please attach copies.
I acknowledge that the particulars given by me in this application are in every respect true.
I have read and understood the academic regulations relating to this programme and are aware of my responsibilities
Nominator
Signature
Date
Primary Supervisor
Signature
Date
Co-Supervisor
Signature
Date
Additional Supervisor
Signature
Date

REFEREES:

Please enter the names, addresses and status of TWO referees who should be able to comment on your academic suitability for research.
Referee
Status
Email Address
Referee
Status
Email Address
DECLARATION BY APPLICANT:
I acknowledge that the particulars given by me in this application are in every respect true.
I have read and understood the academic regulations relating to this programme and are aware of my responsibilities
I also confirm that I meet the English Language entry requirements for UCD.

Please attach certificates if applicable
NAME
SIGNATURE
DATE

SECTION 3: (To be filled out by the SMMS Research office)

RMP (Chair):

Title: / Last name: / First name:
E-mail :
Biomedical Research Degree Committee Meeting
MPB Meeting
Acceptance
SRI Rec.
RMP recommendation
Notification