Application for Study Abroad at
Queen Mary, University of London
Please read the sections on Applying to Queen Mary and Choosing Courses in the Study Abroad Guide
(or on the website) before completing this form. Please complete the form in block capitals and black ink.
Application for admission in (tick as appropriate):
c Autumn semester 2014
c Spring semester 2015
c Autumn semester 2015
c Spring semester 2016
c Academic Year 2014/15
c Academic Year 2015/16
Personal Details
Title:
Given name(s): [Please list ALL]
Family name:
Date of Birth (d/m/yr):
Gender:
Nationality:
Country of permanent residence:
Permanent home Address (please give dates when this address should be used):
Telephone:
Fax:
email:
Address for correspondence (if different – please give dates when this address should be used):
Telephone:
Fax:
email:
Disability: All applications are considered on academic merit in accordance with the College’s commitment
to promoting equal opportunities for all applicants. It would assist us in offering you appropriate advice if you
would give brief details of any disability or special requirements you have in the space provided below
(Please attach supplementary sheets if required):
A detailed guide outlining current policy and provision for students with special needs is available from the
Disability Coordinator, the Admissions Office or the College Website. Please contact us if you would like a copy.
If you would like to discuss your needs before submitting this application, you can talk in confidence to the
Disability Coordinator on + 44 (0)20 7882 3132.
Education
Home College:
Major:
Courses you are currently studying:
Previous colleges attended (if any):
Current Cumulative GPA:
Module selections
Autumn semester
Module code Module title
Spring semester
Required
class?
Module code Module title
Required
class?
References
Please provide contact details of your referee(s) here. The references can either be enclosed with your application
or sent separately.
Name:
Name:
Address:
Address:
Telephone::
Telephone::
email:
email:
Declaration
All applicants must read and sign the following declaration.
• I certify that the statements made by me on this form are correct. I understand that the College reserves
the right to withdraw any offer it may make, should any statement in this application prove to be false.
• I confirm that, if admitted to the College, I will conform to all College Regulations.
• I understand that the College reserves the right to withdraw or alter any course at any point before the
start of the academic year in which that course is due to be offered.
Signature:______________________________________
Date:______________________
Returning your application:
Deadline: 04/01/2014
Please send your completed application form to:
Education Abroad Office
695 Park Ave., E1447
New York, NY 10065