CONTRACT COURSES REGISTRATION CARD

YOKOHAMA NATIONAL UNIVERSITY

Course:8th August 2016 – 2nd September 2016

Accommodation : 7th August 2016 – 3rd September 2016

FAMILY NAME: (MR/MRS/MISS/MS): / MS. SUZUKI
FIRST NAME: / JUNKO
ADDRESS: / FUJI VIEW MANSION 707, SAKAIGI 68-5, TOTSUKA
CITY: / YOKOHAMA
COUNTRY: / JAPAN / TELEPHONE: / 045-339-3553
NATIONALITY: / JAPANESE / FAX: / N/A
EMAIL: / / PASSPORT No.: / 564356773
NEXT OF KIN/EMERGENCY CONTACT: / MOTHER
NAME: / MASAKO SUZUKI
ADDRESS: / CHUNAGON BUILDING 203, OKI 79-2, KITA-KU
CITY: / OKAYAMA / COUNTRY: / JAPAN
TELEPHONE: / 086-333-3333
PERSONAL INFORMATION / MALE: FEMALE: / SMOKER:
NON-SMOKER: / AGE: 18
DATE of BIRTH: 13 /MARCH /1998
ACCOMMODATION / Bed and breakfast and 4 evening meals per week. No access to cooking facilities.
DIETARY REQUIREMENTS / VEGETARIAN: Yes No Other: Other:
MEDICAL
(e.g. allergies, medical conditions) / Do you regularly take any medication? Yes No
If ‘yes’ give details:Theophylline (FOR NIGHT-TIME ASTHMA SYMPTOMS)
Do you have any medical condition? Yes No
If ‘yes’ give details:ASTHMA
PETS / Do you object to pets in the house? Yes No
If ‘yes’ give details of which pets:CATS
EXPERIENCE OF STUDYING/LIVING ABROAD / COUNTRY:
/ GIVE DETAILS:
LEVEL OF ENGLISH / Post-Elementary Lower Intermediate Intermediate
Upper Intermediate Advanced

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I certify that the information I have provided here is true and correct and understand that the University has the right to withdraw any offer

made or cancel any registration if any of these statements prove to be incorrect. I accept full responsibility for the information I have provided on this form.

CRIMINAL CONVICTIONS

Do you have any unspent criminal convictions? NoYes

You are required to indicate whether you have any relevant criminal convictions. Relevant criminal offenses include convictions, cautions, admonitions, reprimands, final warnings, bind over orders or similar involving one or more of those listed below:

  • Any kind of violence including (but not limited to) threatening behaviour, offences concerning the intention to harm or offences which resulted in actual bodily harm
  • Offenses listed in the Sex Offences Act 2003
  • The unlawful supply of controlled drugs or substances where the convictions concerns commercial drug dealing or trafficking
  • Offences involving firearms
  • Offences involving arson
  • Offences listed in the Terrorism Act 2006

Convictions that are spent (as defined by the Rehabilitation of Offenders Act 1974) are not considered to be relevant. Applicants who indicate they have a relevant conviction will not be automatically excluded from enrolling. However, you may be asked to provide additio0nal information relating to your conviction. If you are convicted of a relevant criminal conviction after you have enrolled, you must inform Reception immediately.

English Language Education, The Centre for Open Learning, The University of Edinburgh, Paterson’s Land, Edinburgh EH8 8AQ

Tel: +44(0)131 650 6200 Email: