Reference Form
Postgraduate Studies
CAIRN Consortium(Nepal)

Application for Admission to CAIRN/SXC  Postgraduate Studies
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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

 

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