MRC UCL-Birkbeck PhD Programme

APPLICATION FORM: Section A

APPLICATION

PLEASE INDICATE WHICH RESEARCH THEME YOU HAVE CHOSEN:

Experimental and Personalised Medicine
Fundamental Mechanisms of Disease
Neuroscience and Mental Health
People, Populations and Data Across the Life Course

OR

I am applying for an iCASE project / *Please give project title(s) if known

OR

I am applying for an NPIF studentship / *Please give project title(s) if known
PERSONAL DETAILS
Surname/Family Name / First Name(s) / Title (Mr/Mrs etc.)
Sex / Date of Birth / Nationality(s)
Male / Female
Passport Number / Passport Issue Date / Passport Expiry Date
Country of Birth / Country of Ordinary Residence
Current Address
Time at this address: / *If less than 3 years please provide further addresses on separate paper
ENGLISH LANGUAGE
Is English your first language? / If “No” have you?
Yes / Taken an English test in the last two years?
No / Been educated at degree level in English?
Detail any work experience or education that you have undertaken in English.
Provide the date and scores(s)/grade(s) of any English language test taken. Any work experience, education or test must have been within three years of your proposed start date at on the programme. A copy of the test certificate should be enclosed with this application.
FUNDING
I am eligible for full MRC funding as described in their Guide to Student Eligibility document

I am an EU student eligible for “Fees Only” MRCfunding
I am not eligible for MRC funding / *Please indicate below how you will finance your studies
Personal/Family Resources / *Please provide details of other scholarships secured.
Loan
Other scholarship*
DISABILITY/SPECIAL NEEDS
Do you have a disability? / Please also complete the disability and ethnic origin monitoring form enclosed. Any information on disability will be passed (in confidence) to UCL’s Disability Co-ordinator. If you have a disability that may require reasonable adjustments to be put in place, you must independently contact the Disability Co-ordinator to discuss your needs.
Yes
No
REFEREES
Give details of the two people who can provide a reference for your application.
Please send both referees a copy of the MRC DTP reference form. References must be received by 5pm, 12th January 2018. It is the applicant’s responsibility to ensure references are received on time.
Name / Name
Position / Position
Address: / Address:
Telephone / Telephone
Email / Email
APPLICANT’S DECLARATION
To the best of my knowledge, the information on this application is accurate and complete.
Please note that the MRC DTP reserves the right to refuse admission or to terminate a student’s attendance should it be discovered that he/she has made a false statement or has omitted significant information. If you are offered a place, you will be required to provide evidence of your qualifications.
Data Protection Act 1998: I agree to the MRC DTP processing personal data contained on this form, or other data which may be obtained from me or other people or organisations while I am applying for admission to the programme. I agree to the processing and disclosure of such data for any purpose connected with my studies, or my health and safety while on the premises of the consortium institutions or for any other legitimate purpose.
Signature
Date

MRC UCL-Birkbeck PhD Programme

CHECKLIST

Please submit this form, together with:
Application Form: Section B
Official complete transcripts of all completed degrees / N/A
Official partial transcripts of any on-going studies. / N/A
Where appropriate, an English language test certificate / N/A
Academic CV (max two sides and including A-Level grades, or equivalent)
Copy of Passport
Confidential personal information monitoring form

Please sendall your application documents in a singleemail to:

Please include the name of the theme you have chosen or CASE as appropriate in the subject header for your email.

PDF documents are preferred.