一学期、一学年交流申请表.pdf
一学期、一学年交流申请表.pdf
Study Abroad Application Form 2017 Application form 1. PERSONAL DETAILS Surname (Family name): Forename/s (Given name/s): Title: Mr/Ms/Miss/Mrs etc.: Date of Birth (DD/MM/YY): Gender: Male ( ) Female: ( ) Passport Number: Nationality (as on your passport): Which visa do you intend to obtain. Tick as appropriate. Student Visitor Visa (required for 1 Semester Study) □ Tier 4 (General Student Visa) (required for full time more than 6 months study) □ Current Address: Post Code: Phone: Email: Do you have any special needs? The information you provide will be treated confidentially and will not affect judgements concerning your academic suitability for a course. Please Tick No disability. You have a social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder. You are blind or have a serious visual impairment uncorrected by glasses. You are deaf or have a serious hearing impairment. You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy. You have a mental health condition, such as depression, schizophrenia or anxiety disorder. You have a specific learning difficulty such as dyslexia, dyspraxia or AD(H)D. You have a physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches. You have a disability, impairment or medical condition that is not listed above. You have two or more impairments and/or disabling medical conditions. Page 1 of 5 Emergency Contact Name of a relative: Relationship to you: Address: City: Country: Post Code or Zip Code: Email: Phone: Agent details (if applicable) Agent name 2 PROGRAMME INFORMATION Programme Title at BCU (Choice 1) Programme Title at BCU (Choice 2) Undergraduate ( ) Postgraduate ( ) Programme Title at your home University Name of your home University For Undergraduate Entry Entry Year at BCU Year 1 entry ( ); Year 2 entry ( ); Year 3 entry ( ) Study Length at BCU 1 Semester ( ); 2 Semesters ( ) Current Year of Study at your home University Year 1 ( ); Year 2 ( ); Year 3 ( ); Year 4 ( ) For Postgraduate Entry Study Length at BCU 1 Semester ( ); 1 Year ( ) Current Year of Study at your home University Year 1 ( ); Year 2 ( ); Year 3 ( ) 3 ACADEMIC QUALIFICATIONS Please enter the details of the highest level of qualification you currently hold. Qualification From Year Major/Programme To Year Name of University Results Page 2 of 5 English Proficiency: Please include your IELTS/TOEFL/Pearson Test of English result below: IELTS: TOEFL: BCU Internal Test: Pearson Test of English: Other Secure English Language Test (SELT) and score: Other: 4 EMPLOYMENT, WORK and VOLUNTARY EXPERIENCE Nature of work/training Name of organisation Full-‐time or part-‐time From Year To Year 5 CRIMINAL CONVICTIONS The University has a duty to ensure the safety and security of its students and staff. Please tick box if either of the following statements applies to you: I have a relevant criminal conviction that is not spent I am serving a prison sentence for a relevant criminal conviction Convictions that are spent (as defined by the Rehabilitation of Offenders Act 1974) are not considered to be relevant and need not be disclosed. The definition of a relevant conviction is one for offences against the person, whether of a violent or sexual nature, or for offences involving unlawfully supplying controlled drugs or substances where the conviction concerns commercial drug dealing or trafficking. Such a disclosure does not automatically exclude you from the application process but the University reserves the right to ask for further information about the conviction. Page 3 of 5 6 PERSONAL STATEMENT 7 DECLARATION I confirm that the information given on this form is true, complete and accurate and that none of the information requested or other material information has been omitted. I accept that if it is discovered that I have supplied false, inaccurate or misleading information, Birmingham City University reserves the right to cancel my application, withdraw its offer of a place or terminate attendance at the University and I shall have no claim against Birmingham City University in relation thereto. Applicant’s name Applicant’s signature Date Please ensure you have the following documents to support your application: ¨ English Language Qualification ¨ Copy of your passport photo page ¨ Any supporting documents (Academic qualifications or work experience) Upon completion please email this form and your supporting documents to application@bcuchina.cn 021-‐62888511/12/13 BCU China Office, Shanghai www.bcuchina.cn Page 4 of 5 Equal Opportunities Monitoring Name: Date of Birth: THIS INFORMATION WILL NOT BE GIVEN TO ADMISSIONS TUTORS INVOLVED IN MAKING DECISIONS ABOUT YOUR ELIGIBILITY FOR THE COURSE. As part of its equal opportunities policy, Birmingham City University monitors applications by gender, ethnic origin and disability. Provision of information on ethnic origin is voluntary but we hope you will agree to provide it to assist us to monitor our equal opportunities policy. Please tick the appropriate box. 10 White 21 Black or Black British - Caribbean 22 Black or Black British - African 29 Other Black background 31 Asian or Asian British - Indian 32 Asian or Asian British - Pakistani 33 Asian or Asian British - Bangladeshi 34 Chinese 39 Other Asian background 41 Mixed - White and Black Caribbean 42 Mixed - White and Black African 43 Mixed - White and Asian 49 Other Mixed background 80 Other Ethnic background 98 Do not wish to provide information Page 5 of 5