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Application Form
Thank you for your interest in our MSc Clinical Optometry Modules. The application form must be completed in English. Any supporting documents not in English must be accompanied by a certified translation.
Funding Information
Self Funded: If you are paying your own fees, please tick the relevant box on page 5 and complete the Notification of Fees form (last page of
this application form). The following methods of payment are accepted and must be submitted with your application form in order to be fully registered on the module(s). - Debit or Credit card (All major cards are accepted except American Express and Diners Club) - complete the Debit or Credit - For security reasons students are advised not to pay in cash.
Fully Employer Funded: If your employer is paying your fees, please tick the relevant box on page 5 and arrange for your budget holder to complete
the Notification of Fees form in order that we can send them an invoice (last page of this application form). You must ensure that the appropriate section is fully completed, signed and stamped by your sponsors authorised representative. You must submit this form with your application form in order to be fully registered on the module(s).
Part Self Funded: If you are going to be part funded by your employer, and part self funding, please tick the relevant box on page 5 and complete
the Notification of Fees form (last page of this application form). If you are paying by cheque for your part of the fee, please remember to enclose this with your application form. We will send an invoice to your employer for their part of the fee. The costs for 2012/13 are 730 Home/EU and 1,060 Overseas per module. Please note that fees are likely to change for subsequent years. Applicants need to pay an extra 80 for Glaucoma and Principles of Prescribing examinations. CET day the first lecture day of each module costs 200. Research Methods and Statistics fee 440. Clinical Supervisors employed by City are entitled to attend CET days at no charge, or receive a discount of 100 per module. Staff confirmation will be requested. Visiting Clinicians are entitled to a discount according to years of service. Cancellation Fees: Please note there is a 150 charge for cancellations made within 4 weeks of the module start date. Please let us know if you have any additional needs arising from a disability or health condition.
Application Process
In order for us to ensure your application is processed in due time, please ensure we receive your form at least 6 weeks before the module is due to commence. Please send your completed application form to the address below. To find out if a module is suitable for you or for further information please contact: Rita Kaur City University London School of Health Sciences Health Building Northampton Square London EC1V 0HB Email: rita.kaur.1@city.ac.uk Alternatively you can fax you completed application, marking it for the attention of Rita Kaur: Fax: +44 (0)20 7040 5808
Application Form
Please note this can be amended at a later date, but we would like to know what you ideally hope to achieve. Four Modules to achieve a Postgraduate Certificate in Clinical Optometry within three years Eight Modules to achieve a Postgraduate Diploma in Clinical Optometry within six years Eight Modules plus a dissertation and Research Module to achieve a Masters Degree in Clinical Optometry within seven years
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Module Information
Code Module Title Module Date
If Yes please state your Student Number (if known) Surname Date of Birth Known as Name (if applicable) Gender (please tick)
M
First Name
Previous Name(s) (if changed) Permanent Address .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. ............................................ Tel No. (Home) Tel No. (Work) Tel No. (Mobile) Postcode ............................
D D/M M/Y Y Y Y
Correspondence Address (if different to permanent address: not a work address) .......................................................................................................... .......................................................................................................... .......................................................................................................... .......................................................................................................... ............................................ Postcode ........................................
Nationality (please state dual nationality) ........................................... Country of Permanent Residence ......................................................... Country of Birth .................................................................................. If a holder of a UK entry visa please state conditions of entry .......................................................................................................... Date of Arrival into the UK (dd/mm/yyyy) ............................................. Passport Number ............................................................................... (if you are not a UK/EU citizen)
Next of Kin (Contact Number) Dutch equivalent Registration Number Overseas equivalent Registration Number
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Advertisement Prospectus
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Letter Event
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Email Other
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Subject
Level
Grade
Date Completed
Overseas Applicants English Language Qualifications (To be completed by applicants if English is not your first language)
If English is not your first language, you must show evidence that your command of the English language is suitable for entry to degree-level studies. A pass in one of the following qualifications is the minimum expectation of City University London: IELTS Test of the British Council at 7.0 TOEFL Internet based total of 107 or above. Please indicate which tests you have taken, or have registered to take. Date Awarded Awarding Body Qualification Grade
Subject
Degree or Equivalent
Grade
Date Completed
Professional Qualification
Awarding Body
Date of Award
Clinical Background
No
Dont Know
Information Refused
No
Signed ....................................................................................................................
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Applicants Signature
D D/M M/Y Y Y Y
Sponsors Signature Date
D D/M M/Y Y Y Y
o 39 Other Asian background o 41 Mixed White and Black Caribbean o 42 Mixed White and Black African o
43 Mixed White and Asian
o 49 Other Mixed Background o 80 Other Ethnic Background o 90 Not Known o 98 Information Refused
o 34 Chinese
If you have a disability or a long term medical condition we can try and offer study and examination facilities which meet your needs. (Please contact the Disability Officer to discuss.) Do you have a disability? Yes
No
o o 06 Mental health difficulty o 07 Unseen disability, e.g. diabetes or epilepsy o 08 Multiple disabilities o 09 Other disability o 10 Autistic Spectrum Disorder o
98 Information not sought
I agree that the information given on this form may be processed by City University London in accordance with the Data Protection Act, in particular, for the purposes of the equal opportunities monitoring. I agree to the storage of this information on manual or computerised files. Signature Date
D D/M M/Y Y Y Y
6
This completed form should be returned (with a covering letter from your sponsor if they are paying ALL/PART of your fees) to
Rita Kaur, City University London, School of Health Sciences, Health Building, Northampton Square, London, EC1V 0HB
Course Details Code Title Start Date In the unlikely event that the fee above is incorrect, we reserve the right to charge you the correct amount and to require payment of any shortfall as a condition of completing your registration. The payment options are as follows (please tick the method by which you wish to pay and complete the necessary details): Fee Payable Student Name and Address Student Number
1.
I enclose a cheque () for the Full/Partial amount made payable to City University London My sponsor has agreed to pay the Full/Partial amount agreed for the above course/module(s), so please send an invoice to my sponsor as follows: Job Title ...............................................................................
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Please note that we will not be able to complete your registration if you do not enclose a letter of confirmation from your sponsor. You will be liable for payment of fees should your sponsor fail to provide payment.
3.
I authorise the University to charge my credit card/bank account with the Full/Partial amount as agreed in respect of my fees
The University accepts payment by Maestro, Visa Delta, Access, Visa and MasterCard. We do not accept American Express or Diners Club cards. Card Holder Name (as shown on card) .....................................................................................................................................................
Card Holder Address ........................................................................................................................................................................ ...................................................................................................................................... Telephone Number ..................................................... Card Number (16 digit number) Postcode .............................................
....................................................................
(Switch/Solo) Issue No. ......... Expiry Date .................... Valid From .................... Security No. (3 digits on back of card) ......................
Date ....................................................
Start Date