The Language Centre,
University College Cork
STUDY / WORK
PROGRAMME
2013/2014
REGISTRATION FORM
Personal Details
First Name(s): ________________________________________
Family Name: ________________________________________
Address for Correspondence:
Registration Form must
be accompanied by
two passport size
PHOTOGRAPHS for a
Student ID Card and file.
Scanned photos will not be
accepted.
Home Address (if not the same as above address):
________________________________________________________________________________
Date of Birth: _____/_____/_____
Telephone No: _________________________
Male or Female. _____________________
Nationality: ___________________________
First Language: ______________________
Second Language ______________________
Mobile. No. ___________________________
E-mail: _______________________________
Do we have your permission to use your e-mail and/or mobile no. for publicity in the future: Yes/No (please circle one)
Course Start Date:
__________________ [Monday]
Host family Request
Yes
No
Start Date ______________________ Depart Date ______________________ No. Weeks ______
Level of English (please circle one):
Elementary

Upper Intermediate
Lower Intermediate 
Advanced

Please summarise in no more than 20 words your main needs in English:
Intermediate
Proficiency


Where did you hear/read about this course:
________________________________________
Agent
Agent Name _______________________
Your university
Name of University __________________________
Web Site
Other student
Please give details e.g. name of website: ____________________________________________
REGISTRATION CHECKLIST
1. Send completed Application Form + Educational History + Proof of current English level
e.g. IELTS result, Cambridge Certificate, OR, complete the attached composition.
2. Attach two passport size photographs.
3 Full fees must be paid in advance of course start date (if your Application is approved).
[please email [email protected] when you have paid Fees]
4. A deposit (non-refundable) of €250.00 must be paid when an offer of a place is made.
Fees can be paid by (international) bank draft drawn on a Irish bank and made payable to
“Language Centre, UCC” or by lodging monies directly into the Language Centre UCC account
(details below) or by credit/debit card (e-mail [email protected] for details).
 We do not accept personal cheques as payment.
 Places will be allocated on a first-come first-served basis.
 Minimum numbers are required to form a class, if minimum numbers are not met we reserve
the right to transfer students to a combination of other classes suited to their level, if it is
possible, otherwise a refund will issue.
Bank Details:
Bank Name:
Bank of Ireland, 32 South Mall, Cork, Ireland
Account Name:
UCC Language Centre
Account Number:
87099989
Sort Code:
90-27-68
IBAN Number:
IE58 BOFI 9027 6887 0999 89
Bank Identifier Code: BOFIIE2D
All bank charges to be paid by
student.
Completed Application Forms should be returned to:
The Language Centre (English as a Foreign Language), O’Rahilly Building, University
College Cork, Cork, Ireland. Please mark envelope “Intensive Programme”.
If you have a query on your application, please send an e-mail to: [email protected].
Tel: +353 21 4902043 or 4902898 Web: www.ucc.ie/esol
For Office Use Only
Amount Received: ________
Receipt number: _____________
Date: _____________
Amount Received: ________
Receipt number: ______________
Date: _____________
Total Cost of Course: €5,000
Date acknowledgement letter sent:
__________________________________________________
Date Acceptance details sent to student:
_______________________________________________
Comments:
____________________________________________________________________