Reference Form
Postgraduate Studies
CAIRN Consortium(Nepal)
Application for Admission to CAIRN/SXC Postgraduate Studies
------------------------------------------------------------------------
yr
ref:
Number (for office use only):
confidential
Please complete this form.
1. PERSONAL DETAILS
Surname/Family Name :
Previous
Surname/Family Name (if relevant) :
Other Names (in full) :
Title :
Home email contact address :
Home postal address :
Street/No:
GPO:
Area:
City:
Postcode:
State:
Country:
(Address
is valid from …./…... /..… to …./….../….)
Telephone No. (including
area code):
Fax No. (inc. area code):
(Other email / cc: optional):
Confidentiality secured data
Nationality:
Date of Birth
date :
month :
year :
Sex: Male/Female
First Language
(if other than English) :
Disability/Special Needs :
Passport Details
Passport Country:
Passport Number:
Paasport validity (must be 6 months valid)
Passport issued on:
Passport expires on:
Passport issued where:
Passport issued by:
Did you already applied for a visa (Yes/No) :
in the EU
: (specify
type of visa) :
in UK
:
(specify type of visa) :
Did you already travel to the EU or UK
(specify) :
How long did you stay in the EU or UK (specify) :
Immigration Procedure
You will have one Home-country Certificate
of Residence (visa required):
You (will) have one Health Insurance (visa
required):
Specify:
Did you already applied to Consulate or Immigration
for interviews:
Specify:
You will have one contact address in case of
urgency (optional):
2. CAIRN STUDY :
Option Chosen:
Full or Part-time:
Requested Year/period for Entry:
Define your Topic of Research
Project:
Have you previously applied for admission to
Postgraduate
studies in the EU or UK :
If yes, please specify your application :
3. FINANCE
Name of individual or organisation providing funds for
study :
Are your studies self-financed :
Is any other sponsorship
proposed :
Please specify evidence of financial support required prior to
visa :
Bank account (can also be used for refunding!):
Bank
identification:
Account holder's name:
Is is in local currency only / or
USD compatible:
4. ACADEMIC BACKGROUND
Please give details of your degree :
Any other equivalent qualification :
Awarding Institution or Body :
Official Name of Qualification :
(ie: BA, BSc, MA, MSc, PhD, Diplom,
Maîtrise, Ptychion, etc)
Subject(s) of degree:
Result:(e.g. class, GPA,
etc)
Date of Award:
Name and full postal address of the institution
at which you have studied
for your degree:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Dates of Attendance:
From: Month
____________________________ Year
__________________
To:
Month ____________________________ Year
__________________
NOTE: If you accept to undertake
postgraduate studies,
it will be necessary to prove the awarding of your
degree.
Other Degrees :
Higher Degrees and/or Professional Qualifications :
Title(s) Date(s) of Award(s) :
Name of the institution or awarding body
:
English Language Proficiency – applicable only if your first language is not
English :
Please give TOEFL, IELTS or CPE score :
Copies of the relevant
certificates need to be attached.
Name of test: ____________
Score:
_________
Date of most recent test: ______________________
Date of
forthcoming test: ______________________
Use this space to add any further
information regarding your English Language proficiency
(e.g. if your
undergraduate course was taught through the medium of English).
You may be
required to undertake further studies in English before you commence your
postgraduate course
5. SUPPLEMENTARY INFORMATION
Please use this space to add these
information to your application.
Provide a brief outline of the proposed
research topic :
-
-
Motivation for the chosen scheme of study:
-
-
Applicants seeking admission on the basis relevant experience should use
this space to outline their career upto date and/or provide details of
any
relevant training qualifications (eg : ICT- diplomas,
certificates, etc.) :
-
-
6. ACADEMIC REFERENCES
Applications cannot be processed
without references.
Please provide the names, addresses and positions of two
academic or work-related referees.
a-
b-
7. DECLARATION
I confirm that the information provided on
this application form is true, complete and accurate,
and that no
information requested here or other material information has been omitted by me.
I understand that CAIRN reserves the right to establish the authenticity of
my application and
that it reserves the right to cancel my application if
false information has been provided.
Signature of Applicant:
Date:
Please reconfirm Ur email contact address:
Please return this form to CAIRN(Nepal) by email attached file (DOC)
at :
leon@sped.ucl.ac.be
END//