International Exchange Student Application Form

All fields must be completed.

1 Your Personal Details

March 09

Title / Gender
Surname/family name (as on passport)
First names (as on passport)
Previous family name (if changed - e.g. through marriage)
Date of birth(dd/mm/yy) / Nationality
Personal email address
Contact telephone number (with code)
Permanent home address
Home telephone number (with code)
Dates you will be at this address
Correspondence address (if different from above)
Dates you will be at this address

March 09

2 Programme of Study

March 09

School/department
Programme title at home institution
Level of study(eg bachelor, master)
Start date (dd/mm/yy) / Expected end date (dd/mm/yy)

March 09

3 Educational Qualifications–please attach a transcript of your studies to date

March 09

University/Institution / Subject / Start date / End date / Expected qualification

4 English Language Qualifications–to be completed by all applicants whose first language is not English or were not educated in English

Title of English language test/course / Examining body / Date taken / Grade/mark obtained

5 Additional personal information

Do you have a disability or special need that may require special arrangements?Yes No

Do you have any criminal convictions (or serious criminal charges against you)?Yes No

6 Personal Statement– please use the space below to make a statement in support of your application

7 Academic Reference– please attach your letter of reference

March 09

Referee name and title
Organisation
Position
Email
Address
Telephone number (with code)
Fax number (with code)

March 09

8 Declaration

March 09

Please ensure that you read the declaration below and sign and date the form.

I confirm that the information I have given is correct and that no material information has been omitted. I understand that the University reserves the right to withdraw any offer or cancel a registration made on the basis of information that proves to be false or misleading.

Admission to the University is subject to the requirement that the student will comply with the University’s registration procedures and will duly observe the Charter, Statutes, Ordinances and Regulations.

Signature
Date

March 09

March 09

What to do now
Please tick as appropriate to indicate any additional information you may be supplying with this application for:
I enclose:
Copies of transcripts and/or examination certificates
Academic reference
Any other information relevant to my application / This form should then be returned to:
Roxanne Cavanagh
Inward Mobility Administrator
International Relations Office – B3
University of Surrey
BA Building
Guildford
Surrey
GU2 7XH
UK

University of Surrey Use Only

For completion by Faculty/department / For completion by International Relations Office
Decision on Application: / Date Application Received:
Signature: / Signature:
Job title: / Job title:
Date: / Date:

March 09