Application form

Study Abroad Programme (JYA)

1. Your personal details

Family name First name

Sex (Male/Female) Date of birth

Country of birth Nationality

2. Your address

(a) Home address (b) Address for correspondence (if different)

City City

Country Country

Telephone Telephone

Fax Fax

Email Email

3. Your academic profile

Name of College/University

Address

Present year of study

Academic majors Academic minors

What is your current Grade Point Average? (If applicable)

4. Your level of english

If your first language is not English, please state which English language qualification you hold (eg IELTS, TOEFL or equivalent)

Name of qualification

Score/Grade Date Do you intend to take the test again? Yes No

5. Your proposed study period at the University of Birmingham

Please tick one box only

Birmingham Study Abroad Programme (with English): Birmingham Study Abroad Programme:

April – March October – June

July – March October – December

April – December January – June

July – December

For full details about the different Study Abroad Programme options open to you (including dates), please refer to the Study Abroadbrochure or web-pages.

6. Your programme of study

Module code Module title Credit value

If applicable, please list your ‘reserve modules’ below:

7. Your personal statement

Please use the space below to tell us why you would like to participate in the Birmingham Study Abroad Programme and provide someinformation about yourself, your academic interests and extra-curricular activities. You can attach an extra sheet of paper if you prefer.

studyabroad@bham.ac.ukwww.bham.ac.uk

8. Disability

The University is very willing to help students with disabilities. In order to allow us to provide the best available support for you we needto know about the nature of any disability and how it might affect your studies. This will not affect judgements concerning your academicsuitability for a course, and will be treated confidentially. Please circle the number from the list below which is most appropriate to you:

0 You do not have a disability nor are you aware of anyadditional support requirements in study or accommodation

1 You have dyslexia

2 You are blind/partially sighted

3 You are deaf/have a hearing impairment

4 You are a wheelchair-user/have mobility difficulties

If you have declared a disability, please provide full details on a separate sheet if you will require any special study or accommodationsupport from the University of Birmingham.

9. Further information

What is your source of financial support?

(Information for students from USA: The University of Birmingham’s Federal School Code is G08908)

10. How did you find out about the Birmingham Study Abroad Programme?

Study Abroad Advisor Personal Recommendation Website

Other

11. Declaration

I declare that the information given above is true and complete

Signed Date

Return to: Study Abroad and Exchanges Office, International Office, Aston Webb Building, University of Birmingham, Edgbaston,Birmingham, B15 2TT, UK

Tel: +44 121 414 7695

Please return:

1. Application Form

2. Two references (at least one academic reference)

3. A recent official academic transcript

4. A copy of your English Language Qualification (if applicable)

5 You need personal care support

6 You have mental health difficulties

7 You have an unseen disability (diabetes, epilepsy, asthma)

8 You have two or more of the above disabilities/special needs

9 You have a disability not listed above

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