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Form IC/A

Imperial College London


(University of London)

APPLICATION FOR RESEARCH DEGREE REGISTRATION (DIC, MPhil, PhD, MD (Res),
EngD)

Please read the notes overleaf before completing this form which must be submitted via the
Departmental/Divisional Postgraduate Coordinator to Registry, records@imperial.ac.uk.
The form must be returned within one month of starting research.

A: TO BE COMPLETED BY APPLICANT

Surname (Family Name) in BLOCK LETTERS and Title All other names in BLOCK LETTERS CID Number:



Date of Birth Married Male or Country of Nationality Country of Birth
Day: Month: Year: or Single Female


Department/Centre/ICSM Division Date of commencement
of research programme


Mode: please tick one box only Campus: Silwood Park Charing Cross

Hammersmith Royal Brompton
Full-time Part-time
Northwick Park South Kensington
The following should be completed by PG Medicine applicants only:
St Marys Chelsea & Westminster
% of time devoted to project* ____________________
*Applicants working on their project 79% or less of the time will
be classed as PT and will be following PT Milestones Please tick one box only.

IF NOT A STUDENT PLEASE SPECIFY STATUS HERE
AND STATE YOUR CONTRACT DATES
(eg. Lecturer, Research Assistant, Technician,
Teaching Company Associate)

Permanent Home Address Telephone





Address while attending College (if different from above) Telephone





Next of Kin (or other person to be Relationship to you
contacted in case of emergency)

Address of Next of Kin Telephone

Day:

Evening:

Degree(s) held by Applicant Date of Award Class/Grade Institution Attended (University of London Main Subjects
graduates should state their College)

1.


2.


3.



Signature of student.. Date...

This form should now be passed to your supervi sor(s) for compl etion of Part B overl eaf.

B: TO BE COMPLETED BY SUPERVISOR(S) AND BY
DEPARTMENTAL/DIVISIONAL POSTGRADUATE COORDINATOR


I/We recommend registration for: DIC only MPhil only MPhil MD (Res)
(tick one box only) (not leading to PhD) Leading to PhD

Proposed Field of Study
(PLEASE DESCRIBE RESEARCH IN UP TO 8 WORDS USING BLOCK CAPITALS)







Effective Registration Date Day: Month: Year:


NB: The College will not normally permit more than 3 months backdating of registration

1. Name and CID of Sole or Principal Supervisor Signature Date
Surname, Initials and Title

CID


2. Name and CID of Second Supervisor (IF JOINT SUPERVISION) Signature Date
Surname, Initials and Title

CID


3. Name and CID of Third Supervisor (IF JOINT SUPERVISION) Signature Date
Surname, Initials and Title

CID


I confirm that the proposed supervision arrangements conform to the College criteria for the supervision of research students and that the
students proficiency in English meets College minimum standards.

Signature of Director of Postgraduate Studies or Nominee Date



Notes

1. NAME: Applicants will be registered in the names shown on the evidence of their previous qualifications. In cases of
dispute, further evidence (passport, birth certificate) may be required.

2. EVIDENCE: Applicants will be required to produce satisfactory evidence of their previous qualifications, if they have not
already done so. Photocopies are not acceptable as evidence.

3. REGISTRATION: Applicants will not be officially registered for a higher degree and/or diploma until this form is duly
completed and returned to Registry, Level 3, Sherfield Building, South Kensington Campus. Faculty of Medicine
Divisions and some other Departments require completion of a research plan prior to submission of the IC/A form to
Registry. Applicants intending eventually to submit for a PhD should note that it is College policy that all research
students shall be registered initially for the MPhil degree.

4. SUPERVISORS: All supervisors must complete the relevant parts of Section B above. However persons acting as
academic advisor or mentor or collaborating academic should not be named above.

5. All projects that use human subjects or human tissue must have the appropriate ethical committee approval before such
proposals can be approved.

6. Applicants are advised to familiarise themselves with the booklet Learning to Research: A Code of Practice for
Successful PhD Completion for Research Students and Supervisors.

7. Applicants must conform to the Colleges minimum requirement of proficiency in English language.