Liverpool School Of Tropical Medicine

Liverpool School of Tropical Medicine APPLICATION FORM Personal Details: Title – Dr/Mrs/Mr/Miss/Other:

Surname/Family Name:

First Name:

Middle Name:

Date of Birth:

Nationality:

Passport Number:

Country of Residence:

Previous Last Name (if applicable):

Male/Female:

Permanent Address:

Address for Correspondence (if different)

Telephone No. Mobile No:

Telephone No. Email address:

Programme Application Details: Programme Title: Diploma in Humanitarian Assistance, South Africa. Proposed Start Date: 19th April 2010 – 28th May 2010 The programme includes a choice of options, please indicate your preference here: Health in Emergencies Technical Support Policy and Advocacy Academic Qualifications: (please attach copies of certificates) University/Institution Attended: Degree Title (Subject): Qualification Gained (BSc / Certificate / Diploma): Dates of Attendance DD/MM/YYYY From: Date of Award DD/MM/YYYY:

To:

Professional Qualifications: (please attach copies of certificates) Please give details of any additional professional or other qualifications

Employment History: (if applicable) Position Held Dates Employer & Country

Brief Description of Responsibilities

(Please continue on a separate sheet if necessary) English Language Qualifications: (for applicants whose first language is not English) We require a minimum score of 6.5 for the IELTS or in the TOEFL examination, 570 for the paper-based test OR 88 in the iBT test. IELTS Score Date Taken TOEFL

Score

Date Taken

Other

Score/Grade

Date Taken

Computer Skills:

Other Relevant Skills and Experience:

Future plans (what do you intend to do after completing this programme?):

Disability/ special needs: Do you have a disability? Yes/ No Please also complete the Equal Opportunities Monitoring form attached. Any information about your disability will be treated in confidence.

Criminal Convictions: Do you have any criminal convictions? (If you do not answer this question we cannot process your application) Yes

No

If you have answered yes, please give details of the conviction in terms of sentence served or caution received.

*Referees: (separate form attached) NB. Applicants are requested to ask their referees to e-mail, post or fax references directly to the Programme Administrator as soon as possible. References by e-mail should be followed by a signed copy by post / fax.

Name

Name

Position

Position

Address

Address

Email

Email

Telephone No.

Telephone No.

* Note concerning referees: Referees should be Senior Academic and/or Professional persons who are currently responsible, or have recently been responsible, for supervising you. Close personal friends and family are not acceptable as referees. Referees should be Senior Academic and/or Professional persons who are currently responsible, or have recently been responsible, for supervising you.

Personal Statement: (Please give details of why you applied for the programme and what you expect to gain from attending the programme)

Financial Support/Sponsorship • Candidates must provide evidence that they will have sufficient funds available for their fees and maintenance during the programme. If self-funded, please enclose a recent bank statement. •

If sponsored please state the name of authority responsible for payment of tuition fees and enclose written confirmation from sponsors.

•

Please note that family member sponsorship is classified as self-funding, and the requirements for self-funded students apply.

1. Self-funded: Yes / No.

If YES, please enclose a recent Bank Statement.

2. Sponsored: Yes / No.

If YES, please complete the questions below:

Have you applied for a scholarship / sponsorship: Yes / No If ‘yes’, please state name and address of funding body: Have you received a scholarship / sponsorship offer: Yes / No If ‘Yes’, please enclose a copy of your offer letter. If ‘No’, please state the date by which you expect to have received an offer: Please ensure that you notify the Programme Administrator and forward a copy of your offer letter as soon as it becomes available.

Please indicate where you first heard about the programme: Please tick one box University Prospectus Supervisor Education Exhibition/Careers Fair

Venue …………………………………..................

WWW

Please specify ………………………………………

Professional Journal

Please specify ………………………………………

Alumni/Previous LSTM Student Friends/Relatives Other

Please specify ………………………………………

Application forms may be e-mailed or faxed: Fax: 0044 151 705 3347 Eleanor Carr: [email protected]

Telephone: 0044 151 705 3359

Alternatively, applications can be posted to: (Programme Administrator) Liverpool School of Tropical Medicine Pembroke Place Liverpool L3 5QA, UK Check-list Evidence of academic or professional qualifications (including transcripts where necessary) Copies of English language certificates (where appropriate) IELTS / TOEFL / WAEC Evidence of funding. Family member sponsorship is classified as self funding. If a family member is responsible for your fees and living expenses, a bank statement or letter from the bank is required along with a supporting letter. Passport photographs x 2 (with name on reverse) If you have sent your application via e-mail, a jpeg photograph is acceptable I have forwarded the reference forms to two referees Previous Last Name: If you have mentioned a change in name, please provide supporting evidence to support this e.g. marriage certificate. Other relevant items (please specify) Completed Equal Opportunities Monitoring Form

Equal Opportunities Monitoring In order for us to monitor equal opportunities, we would appreciate it if you would answer the following questions.

1.

Ethnic Origin

White British White Irish White Scottish Irish Traveller Other white background

11 12 13 14 19

Black or Black British – Caribbean Black or Black British – African Other Black Background

21 22 29

Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British – Bangladeshi

31 32 33

Chinese Other Asian Background

34 39

Mixed – White and Black Caribbean Mixed – White and Black African Mixed – White and Asian Other Mixed background Other Ethnic Background

41 42 43 49 80

Not Known

90

Information Refused

98

…………………………………………………………………………………………………………..................................................

2.

Disability

.

In the application form we have asked about any disability/ special needs in order that we can provide students with the best support. For planning purposes we would appreciate it if you could identify the most appropriate description to describe your disability, and enter the corresponding number in the above box. Disabilities / Support Required 0

You do not have a disability or are not aware of any additional support requirements in study or accommodation

1

You have a specific learning difficulty (e.g. Dyslexia)

2

You are blind / partially sighted

3

You are deaf / hard of hearing

4

You are a wheelchair user / have mobility difficulties

5

You have Autistic Spectrum Disorder or Asperger’s Syndrome

6

You have mental health difficulties

7

You have an unseen disability, e.g. diabetes, epilepsy, or a heart condition

8

You have two or more of the above difficulties / special needs

9

You have a disability, special need or medical condition not listed above

If you would like to discuss support, access and facilities for disabled people, please contact The Welfare and Accommodation Officer. Rebecca Riley 0151 705 3176 [email protected]