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Personal Details: Title – Dr/Mrs/Mr/Miss/Other: First Name: Previous Last Name (if applicable): Country of Birth: Nationality: Surname/Family Name: Middle Name: Male/Female: Date of Birth:
Passport Number: Country of Issue: Expiry Date: Have you continued to live in your country of birth up to the present day, with no gaps in residence? Yes/No What country have you been living in for the past three years? Do you need to apply for a visa to come to the UK? Yes/No Permanent Address: Address for Correspondence (if different)
Telephone No. Mobile No:
Telephone No. Email address:
Programme Application Details: Programme Title: Proposed Start Date: If the programme includes a choice of modules / options, please indicate your preference(s) here:
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:
IELTS Score Date Taken TOEFL Other Computer Skills: Score Score/Grade Date Taken Date Taken Other Relevant Skills and Experience: .5 for the IELTS examination OR 88 for the TOEFL iBT examination OR 570 for the TOEFL paper-based examination.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.
DTM&H. MTropPaeds. post or fax references directly to the Programme Administrator as soon as possible. for supervising you. .Both referees must be medically qualified persons who hold official appointments. Applicants are requested to ask their referees to e-mail. friends or fellow students are not acceptable as official referees. Close personal friends and family are not acceptable as referees. *Referees: (separate form attached) NB. MIPH . DICHC . disabilities or support needs 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.At least one referee should be a member the academic staff of the institution at which you last studied.Future plans (what do you intend to do after completing this programme?): Health: Details of any health issues.The first referee should be someone in a position to comment officially on your recent work experience in the field of community health. The second referee should be able to comment officially on your previous academic performance. for supervising you. Name Position Address Name Position Address Email Telephone No. Other MSc . Please note that work colleagues. DHA / MHS / MHHPM . please give details of the conviction in terms of sentence served or caution received. or have recently been responsible. MTropID.Referees should be Senior Academic and/or Professional persons who are currently responsible. Email Telephone No. * Note concerning referees: Referees should be Senior Academic and/or Professional persons who are currently responsible. References by e-mail should be followed by a signed copy by post / fax. or have recently been responsible.
Please note that family member sponsorship is classified as self-funding. and the requirements for self-funded students apply. please enclose a recent bank statement. please complete the questions below: • 1.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. 2. please enclose a copy of your offer letter. please state name and address of funding body: Have you received a scholarship / sponsorship offer: Yes / No If ‘Yes’. If YES. • If sponsored please state the name of authority responsible for payment of tuition fees and enclose written confirmation from sponsors. Sponsored: Yes / No. If YES. . Self-funded: Yes / No. 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. If self-funded. please enclose a recent Bank Statement. Have you applied for a scholarship / sponsorship: Yes / No If ‘yes’.
.uk Telephone: 0044 151 705 3359 Diploma in Tropical Medicine and Hygiene Diploma in Humanitarian Assistance MSc in Humanitarian Studies MSc in Humanitarian Programme Management Katie Douglas: c. Please specify ……………………………………… Please specify ……………………………………… Application forms may be e-mailed or faxed to the appropriate programme administrator: Fax: 0044 151 705 3347 Laura Hand: l.uk Telephone: 0044 151 705 3208 MSc in Tropical and Infectious Diseases MSc in Tropical Paediatrics MSc in International Public Health MSc in International Public Health (Humanitarian Assistance) MSc in International Public Health (Planning & Management) Eleanor Carr: e.ac...carr@liverpool.Please indicate where you first heard about the programme: Please tick one box () University Prospectus Supervisor Education Exhibition/Careers Fair WWW Professional Journal Alumni Newsletter Previous LSTM Student Friends/Relatives Direct Mailing Other Please specify ……………………………………… Venue ………………………………….douglas@liverpool..email@example.com Telephone: 0044 151 705 3321 Diploma in International Community Health Care MSc in Biology and Control of Parasites and Disease Vectors MSc in Molecular Biology of Parasites and Disease Vectors MSc in International Public Health (Sexual and Reproductive Health) Alternatively..ac..... applications can be posted to: (Programme Administrator) Liverpool School of Tropical Medicine Pembroke Place Liverpool L3 5QA.e......c.. UK ..ac..
g. Other relevant items (please specify) Completed Equal Opportunities Monitoring Form By submitting this application I agree to LSTM and its associates processing personal data contained in this form. I understand that my personal data will not be disclosed to third parties without my permission. or for any other legitimate reason. or other data which LSTM may obtain from me or other sources. . 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. a bank statement or letter from the bank is required along with a supporting letter. I agree to the processing of such data for any purpose connected with my studies or my health. marriage certificate. Family member sponsorship is classified as self funding.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. welfare and safety. If a family member is responsible for your fees and living expenses.
....Equal Opportunities Monitoring In order for us to monitor equal opportunities...... Disabilities / Support Required 0 1 2 3 4 5 6 7 8 You do not have a disability or are not aware of any additional support requirements in study or accommodation You have a specific learning difficulty (e. diabetes... access and facilities for disabled people.... or a heart condition You have two or more of the above disabilities/difficulties You have a disability....... please contact The Welfare and Accommodation Officer. epilepsy.....uk .....g..... Dyslexia) You are blind / partially sighted You are deaf / hard of hearing You are a wheelchair user / have mobility difficulties You have mental health difficulties You have an unseen disability.. 2.....ac. In the application form we have asked about any disability/ special needs in order that we can provide students with the best support. e..g. Ethnic Origin 10 10 10 14 10 21 22 29 31 32 33 Chinese Other Asian Background Mixed – White and Black Caribbean Mixed – White and Black African Mixed – White and Asian Other Mixed background Other Ethnic Background Not Known Information Refused 34 39 41 42 43 49 80 90 98 White British White Irish White Scottish Irish Traveller Other white background Black or Black British – Caribbean Black or Black British – African Other Black Background Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British – Bangladeshi …………………………………………………………………………………………………………. For planning purposes we would appreciate it if you could identify the most appropriate description to describe your disability. 1...... Rebecca Riley 0151 705 3176 rriley@liv.. and enter the corresponding number in the above box..... special need or medical condition not listed above If you would like to discuss support. we would appreciate it if you would answer the following questions.. Disability .
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