Science@Sea

Multidisciplinary Ship-based training

Undergraduate Application Form

9th to 12th of November 2012

Strategic Marine Alliance for Research and Training

School of Science

Galway-Mayo Institute of Technology

Dublin Road

Galway

Ireland


Section 1: Personal and Academic Details

Please note all fields are mandatory

Personal Details

Surname / First Name
Date of Birth / / / / Male / Female
Address / Email
Home Phone
Mobile
Nationality

Undergraduate Academic Details

Institution
Department
Title of Undergraduate Course
Year of Study / Year 1 / Year 2 / Year 3 / Year 4

Next of Kin Details

Name of Next of Kin (NOK)
NOK Relationship (e.g. Mother)
Address
Home Telephone
Mobile Telephone

Further Information

Please inform us of any special dietary requirements or allergies
Please inform us of any medical issues relevant to going to sea
Please Indicate if you hold the certification opposite. (Not required for attendance) / ENG 11 Medical Certificate / STCW 95 PST Certificate
Yes / No / Yes / No
Please indicate in order of preference which course you wish to attend. / Friday 9th and Saturday 10th November / Sunday 11th and Monday 12th Of November

Section 2: Personal Statement

Please outline how you and your studies would benefit from participating in Science@Sea multidisciplinary ship-based training (one page maximum).


APPLICATION CHECKLIST

HAVE YOU:

§  Completed every part of the application form?

-  Completed Personal and Academic details

-  Personal Statement

CLOSING DATE

Applications must be received by:

Friday 5th of October 2012

Completed application forms should be submitted to:

Applications by post should be addressed to:

Strategic Marine Alliance for Research and Training

School of Science

Galway-Mayo Institute of Technology

Dublin Road
Galway

Ireland

Further application forms and information can be obtained from:

or

http://www.smartseaschool.com/content/sciencesea-courses-2012

Please note that an administration fee of €50 applies to this course payable upon acceptance.

Successful Applicants will be contacted on completion of evaluations by the 15th October 2012