APPLICATION FORM

S3RI Distance Learning Programme in Statistics

Once completed, please return these forms to:
Distance Learning Administrator
Southampton Statistical Sciences Research Institute
Building 44/2003
University of Southampton
Southampton
SO17 1BJ
United Kingdom
Tel: +44 (0)23 80599036
Fax: +44 (0)23 8059 5763
Email:
APPLICATION DATE:
A – PERSONAL DETAILS - Please give a name and address for correspondence.
Full Name:
How you would you like to be addressed i.e. the name your friends use?
Correspondence Address:
House Number or Name:
Street:
Town:
City:
County:
Postcode:
Country:
Contact Details:
Home/Mobile Telephone:
Work Telephone:
Email:
B – REGISTRATION AND COSTS - Please indicate which course you wish to follow by ticking the appropriate box.
CourseFeeTick
Ordinary Level (2 modules)£525
Higher Level modular format (6 modules)£825
Please advise on which Higher Levelmodules you would like to study.
Additional or individual modules£175 each
C – BACKGROUND INFORMATION
Some details of your background will help your tutor to help you more effectively. None of this information will be used for any other purpose.
Your Job / Previous Studies:
1)Please give a brief description of the statistical aspects of your current and previous jobs:
2)Please give a list of your previous studies in mathematics, statistics, economics and relatedsubjects. Indicate briefly the topics covered and the year in which you completed the studies:
3)Have you followed a distance learning or correspondence course before?
YesNo
If yes, please give some brief details:
4)Your personal assessment of your abilities will also help your tutor. Please indicate briefly your strong points and your weak points, e.g. no computing knowledge, lots of practical experience of surveys, find calculus hard.
Weak points:
Strong points:
D – PAYMENT METHODS
Please indicate how you wish to pay the registration fees.Please note we highly recommend paying by card as it is the quickest and most convenient method.
1) Payment by cheque
Please make cheques payable to “University of Southampton” and send with your enrolment form.
2) Payment by credit/debit card
Please call the University of Southampton Income Department with your credit/debit card details:02380 594702 or 02380 593430
Quote the course fee for ‘S3RI Distance Learning for [your name]’and the following number ‘7272 504347101’.
3) I am being sponsored by my employer
Please complete the attached Employer Sponsorship agreement form.

PLEASE DO NOT ATTEMPT TO MAKE PAYMENT UNTIL YOUR APPLICATION HAS BEEN APPROVED.


EMPLOYER SPONSORSHIP AGREEMENT FORM

Distance Learning S3RI Distance Learning Programme in Statistics

We agree to settle invoices raised by the University in respect of Distance Learning course fees totalling £ on behalf of:
Name of student:
Date:
Signed:
Name:
Position in Company:
Reference/Purchase Order No.:
PLEASE EMAIL THE PURCHASE ORDER TO
(If you are paying by Invoice a copy of the Purchase Order is required in all cases prior to start of course)
Company Name:
Company Address:
Building Number or Name:
Street Name:
Town:
City:
County:
Post Code:
Telephone No.: