Sections 1, 2 & 3 must be completed fully. Please also tick and date thedeclaration.

1) Personal Details

Family name:First name/s:

Title: Mr/Ms/Miss/Mrs/DrDate of birth: DD/MM/YY

E-mail: Phone:

Programme of Study:Start date:

UCAS number:Student ID:

Nationality/Citizenship:

(If you are a citizen of more than one country, please list them all)

Nationality of relevant family members:

(If they are citizens of more than one country, please list them all)

1) Mother:2) Father:

3) Spouse / Civil Partner:or I am not married/not in civil partnership

Date of marriage / civil partnership? DD/MM/YY

Are any of your other relevant family members EU / EEA Nationals? (Please List)

2) Immigration Status
Please tick the option that applies to you, and give the dates as requested: /

Please provide the following with returned questionnaire:

British Citizen or Commonwealth National with Right of Abode / Copy of relevant page(s) of passport (including page(s) confirming name and nationality)
Indefinite Leave to Enter/Remain / Copy of relevant page(s) of passport (including page(s) confirming name and nationality) and/or Home Office letter
Refugee status / Home Office letter or refugee travel document
Refused refugee status (or child or spouse of someone refused refugee status) but granted one of the following:
□Exceptional Leave to Enter/Remain
□Humanitarian Protection
□Discretionary Leave / Home Office letter
Time limit on stay
Date last passport stamp/visa was issued:
Date of expiry of most recent permission to stay: / Copy of relevant page(s) of passport (including page(s) confirming name and nationality)
EEA national, other than UK
(EEA members: Austria, Belgium, Bulgaria, Croatia,Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Republic of Ireland, Romania, Slovakia, Slovenia, Spain and Sweden) / Copy of relevant page(s) of passport (including page(s) confirming name and nationality)

If none of the above categories covers you, or your status is likely to change before the start of the course, please give details and provide supporting evidence:

3) Residential History

Date of first entry into the UK/EEA (if applicable):
Please give details of the country / countries in which you have been resident from birth to the present day(Please continue on a separate sheet if necessary):
Country and town/region of residence / Dates of residence
(from – to) Day/Month/Year / Purpose of residence, e.g. Holiday, living with family (specify relationship), employment, full-time study
e.g.London, England / 12/09/2003 to 01/01/2004 / e.g. Living with Family(Mother)
4) Temporary Residence Abroad (Please continue on a separate sheet if necessary)
If you have been ordinarily resident outside the UK and Islands or EEA during the last three years because you, your spouse / civil partner or your parent(s) were/are temporarily working abroad, please give details (including length of time spent abroad and the nature of the work). Please include a copy of the relevant employment contracts or an official letter from the employer covering this period.
Country / Length of Stay
(Including arrival date and leaving date, if appropriate) / Nature of work / Contract type
Did you/your parent(s)/spouse/civil partner have the post abroad at time of departure from the EEA?
Yes/No
Do you/your parent(s)/spouse/civil partner pay tax contributions in an EEA country?
Yes/No
If ‘Yes’ please give details:
Was/is a house or flat maintained in the EEA during the period of employment abroad?
Yes/No
If Yes, was/is it rented/retained for the family's use?
Rented / Retained For Family Use
Please give address, length of possession and provide proof of ownership (i.e. utility bills, documents/deeds of purchase, etc):
How often have you (the applicant) visited the property in the last three years (please provide dates and length of stay):
Do you/your parents plan to return to the UK / EEA on a permanent basis, and if so when?
Use this space to add any other relevant information (continue on a separate sheet if necessary):
5) EEA / Swiss ‘Worker’ & Family
Is there an EEA migrant worker / Swiss ‘worker’ in your family?
Yes / No
If the answer to this question is ‘Yes’ please select which of the following categories applies to you:
Migrant worker
Spouse / civil partner of a migrant worker
Child of a migrant worker
Child of a migrant worker’s spouse / civil partner
The parent, grandparent (etc in direct ascending line) of an EEA (not Swiss) migrant worker AND dependent on the EEA migrant worker
The parent, grandparent (etc in direct ascending line) of the EEA (not Swiss) migrant worker’s spouse / civil partner AND dependent on the EEA migrant worker or on the EEA migrant worker’s spouse / civil partner
6) Refugee/Asylum in the UK
Please Tick any statement that applies to you and provide documentary evidence in support of this
I haveRefugee Status
My Parent / adoptive parent / step-parent / guardian has refugee status
My Spouse / Civil Partner has Refugee status
I am an asylum seeker and I am waiting a decision from the Home Office or the result of an appeal
I have Exceptional Leave to Enter/Remain in the UK
I have been granted Humanitarian Protection in the UK
I have been granted Discretionary Leave in the UK
I have been given the right to stay indefinitely/settlement in the UK within the last three years
Refused refugee status but granted one of the above
If you have been given the right to stay indefinitely in the UKwhen were you given this?
Checklist
Completed Section 1
Completed Section 2
Completed Section 3
Completed all other relevant sections
Provided all relevant documentation

Please remember to enclose photocopied evidence outlining your status. This will help us process your application promptly.

Declaration

By ticking the box I hereby confirm that the information provided above is correct to the best of my knowledge.

Date:DD/MM/YY

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