APPLICATION FOR
ADMISSION AS AN EXCHANGE STUDENT
PLEASE USE BLACK INK, BLOCK CAPITALS AND TICK BOXES AS APPROPRIATE.
PERSONAL DETAILS FOR
OFFICE USE
1. Surname/Family Name (as in passport) 2. First Names (as in passport) 3. Title (Mr/Miss etc.)
Applic. No.
Refs
4. Date of Birth (e.g. 07 Aug 87) 5. Sex ( ) 6. Nationality (as in passport) 7. Country of Permanent Residence
Trans
Day Month Year Male Female H/O/E/X
8. Country of Birth
Exchange
Agreement
9. Home Address 10. Correspondence Address (if different)
English
Language
Requirement
Y/N
Postcode/Zip Postcode/Zip
Tel Tel
Initials
Fax Fax
Email Email
Dates when address is valid From: To:
PROGRAMME OF STUDY FOR WHICH YOU WISH TO APPLY
11. Level of Study ( ) Note: Graduate Exchange Research students should
NOT use this form. Instead they should complete the
Undergraduate Graduate (taught) Visiting Research application form.
12. Home Institution
13. UCL department to which you wish to be admitted*
14. Alternative UCL department(s) you wish to be considered for if your application to the department shown above is unsuccessful*
* Please check that UCL department is covered by the Exchange agreement
15. Duration of Study ( )
Full academic year September - December only January - June only
16. Proposed Starting Date
Month Year
FOR UCL OFFICE USE ONLY. TO BE COMPLETED BY THE DEPARTMENTAL AFFILATE TUTOR AT UCL
ACCEPT ( )
Undergraduate Graduate (taught) Start date
Signature Date Department
Signature Date Department
REJECT
Signature Date Department
Signature Date Department
EDUCATION
17. Please provide details of your education since the age of 18, starting with the most recent. Include details of qualifications to be awarded.
Name of College/University/ Start date End date Qualification Overall class/ Main/minor subject(s) studied
Awarding Body (Month/Year) (Month/Year) (e.g. BA, BSc) grade/GPA
ENGLISH LANGUAGE
18. Is English your first language? ( )
Yes No
If No, detail the grade(s) achieved in the most recent English language test you have taken and/or any work experience or education that you have
undertaken in English. A copy of the test certificate should be enclosed with this application or forwarded later.
SUPPLEMENTARY INFORMATION
19. Please provide a preliminary selection of the individual courses you wish to take as part of your programme of study in the
department(s) indicated (overleaf). Acceptance on individual courses cannot be confirmed before arrival at UCL. For course descriptions
please see the UCL Study Abroad Guide. Please indicate with an asterisk (*) any courses you are REQUIRED to take in order to get credit
for your studies at your home institution.
Depar tment Code Course title Depar tment Code Course title
PERSONAL STATEMENT
20. Please attach a separate sheet with a personal statement describing your academic interests and reasons for applying to UCL.
SUPPORTING DOCUMENTATION
21. Please include two academic references (these can be submitted to us directly by your referees if they wish), a transcript relating to your recent
studies, the Disability and Ethnic Monitoring Form and, where appropriate, an English language test certificate.
SUBMITTING YOUR APPLICATION
22. Our preferred method of receipt for all applications and documentation, including references and transcripts, is by email to affiliatestudents@ucl.ac.uk.
If it is not possible to send certain documents by email, please arrange for them to be posted to:
ADMISSIONS, STUDENT AND REGISTRY SERVICES, UNIVERSITY COLLEGE LONDON, GOWER STREET, LONDON, WC1E 6BT, UNITED KINGDOM
23. Criminal Convictions. You are required to declare whether or not you have any criminal conviction(s). If you answer yes, you are required to
provide further information about the relevant conviction(s). Please note that for the purposes of this exercise a criminal offence excludes minor
motoring offences. All information will be treated as strictly confidential.
Do you have any criminal convictions? ( )
Yes No
SIGNATURE OF APPLICANT
24. UCLs decisions are made in good faith on the basis that all of the information provided by applicants is accurate and complete. UCL reserves the
right to refuse admission or to terminate a students attendance, should it be discovered that he/she has made a false statement or has omitted
significant information. Your signature confirms that to the best of your knowledge, the information on this application form is accurate and complete.
Signature of Applicant Date
ENDORSEMENT STATEMENT. TO BE COMPLETED BY THE EXCHANGE CO-ORDINATOR OR DESIGNATED OFFICER AT
YOUR HOME INSTITUTION
25. I fully support the application of this student, and know of no reason, academic or otherwise, why the student should not be admitted to UCL.
Name Official
Stamp/Seal
Signature
Date
