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School of Health Sciences

Application Form

MSc Clinical Optometry


Please complete all sections in black ink and print clearly. It will take us longer to process your application form if information is missing.

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

What happens next?


We aim to acknowledge all applications within 14 working days. If you have not heard from us during this time, please contact Rita Kaur via rita.kaur.1@city.ac.uk We will send confirmation on receipt of your application, in writing, to your correspondence email address. Please note: you are advised to keep a copy of your completed application form for your records.
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School of Health Sciences

Application Form

MSc Clinical Optometry


Please complete this form using black ink, write neatly and clearly in order for us to process it promptly. Please refer to Guidance Notes

Which of the following are you intending to study? (Please tick)


One Module only

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

o o o o

Module Information
Code Module Title Module Date

Personal Information (To be completed by all applicants)


Have you studied at City University London in the past? Yes o No o Title
Mr/Miss/Mrs/Ms/Dr/Other ..................

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 ........................................

................................................................. ........................................ Ext: ................ .................................................................

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)

Personal Email Address

Next of Kin (Name) GOC Number

Next of Kin (Relationship) Republic of Ireland equivalent Registration Number

Next of Kin (Contact Number) Dutch equivalent Registration Number Overseas equivalent Registration Number

School of Health Sciences

Marketing Monitoring (To be completed by all applicants)


How did you hear about the programme? City University London Other Website Website o Previous/Existing Student o Referral

o o

Advertisement Prospectus

o o

Letter Event

o o

Email Other

o o

Education and Qualifications (To be completed by all UK applicants)


Academic/Professional Education. Start with the most recent and give your Academic and Professional qualifications. List all the courses you have attended after secondary school. Include courses undertaken whilst you were working. These can include degree, diploma and any relevant modules, short courses and study days.

Educational Establishment(s) Attended

Subject

Level

Grade

Date Completed

School of Health Sciences

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

D D/M M/Y Y Y Y Education


Start with the most recent and give your Academic and Professional qualifications. List all the courses you have attended after secondary school. Include courses undertaken whilst you were working. These can include degree, diploma and any relevant modules, short courses and study days.

Educational Establishment(s) Attended

Subject

Degree or Equivalent

Grade

Date Completed

Professional Qualification

Awarding Body

Date of Award

Clinical Background

School of Health Sciences

Parental Education (To be completed by all applicants)


We are required by the Higher Educational Statistics Agency (HESA) to request this information from students studying at undergraduate level, i.e. level 3 or below. The following question is about your parents level of education. This includes parents, adoptive parents, step-parents or guardians who have brought you up. Do any of your parents (as defined above) have any higher education qualifications, such as a degree, diploma or certificate of higher education? Yes

No

Dont Know

Information Refused

Declaration of a Criminal Record (To be completed by all applicants)


Have you been through the Criminal Records Bureau Enhanced Disclosure process in relation to your current employment? Yes

No

Signed ....................................................................................................................

Funding Information (To be completed by all applicants)


Please Tick Self Funded Fully Employer Funded Part Self Funded/Part Employer Funded City University Staff and applying for discount. N.B. staff confirmation required.

o o o o

Ordinances and Regulations of City University London


As a student of City University London you undertake to observe and comply with the Ordinances and Regulations of the University and that, to the best of your knowledge, the information provided is correct and complete. Information about City University Londons Ordinances and Regulations is available at: www.city.ac.uk/about/city-information/governance/ordinances

Data Protection Act 1998


We are collecting this information to process your application and to support your study at City University London in accordance with the Data Protection Act 1998. We may pass information about your progress to other organisations such as a sponsor. Further details in relation to the use of personal data can be found at www.city.ac.uk/dataprotection If you would like more information or have concerns please contact the Head of Information Compliance and Policy via dataprotection@city.ac.uk

Financial Terms and Conditions


All fees are payable prior to commencement of the module. You and your sponsor (if applicable) will remain liable to pay any outstanding debt, interest or administrative charges that may be levied in respect of any delay in the payment of fees. If you leave employment with your sponsor you will remain liable to pay any outstanding debt, interest or administrative charges that may be levied in respect of any delay in the payment of fees. Legal action may be taken to recover any amount overdue. The University may use external agencies to assist in the collection of fees if you fail to pay by the due dates. Any non-payment of fees will result in the removal of access to computing and library services and will necessitate in your withdrawal from the University. Cancellation Charges for Self Funded/Employer Funded All cancellations must be done in writing or by email to rita.kaur.1@city.ac.uk Cancellations must be received 4 weeks prior to the start of the programme. Please note we do not accept telephone cancellations. The University reserves the right to charge a cancellation fee of 150. If you do not attend the programme and have not previously informed us, fees are non-refundable. NB: Please note that fees are subject to change.

Declaration (To be completed by all applicants)


I confirm that I have read and understood and agree to the Ordinances and Regulations of City University London and the Financial Terms and Conditions. I agree that information given, both in writing and verbally, may be used by the University in accordance with the Data Protection Act 1998. Applicants Name Date Sponsors Name Position
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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

School of Health Sciences

Equal Opportunities Monitoring Form


(To be completed by all applicants)
Thank you for providing this information which on receipt will be detached from your application and used only for monitoring purposes. City University London, confirms its commitment to equal opportunities in all its activities. The University must not discriminate against an applicant on any of the following grounds: political belief, gender, sexual orientation, age, disability, marital status, race, nationality, ethnic origin, religion or social background. The information you give is in confidence and will not be seen by or made known to any sector. It will be used only to monitor the operation of the Equal Opportunities Policy and will not be made available to Admissions Tutors. Our equality and diversity policy can be found at www.city.ac.uk/hr/policies/equality-diversity/equality-diversity

Please indicate with a tick where appropriate


Ethnic Origin In order for us to assist in our Equal Opportunities monitoring please tick one of the following boxes, which best describes your Ethnic Origin.

o 10 White o 21 Black or Black British Caribbean o


22 Black or Black British African

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 29 Other Black background o o o


31 Asian or Asian British Indian 32 Asian or Asian British Pakistani 33 Asian or Asian British Bangladeshi

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

o 01 Dyslexia or other specific learning difficulty o 02 Blind/partially sighted


Tick one of the following boxes if you wish to declare a disability or long term medical condition.

o 03 Deaf/hearing impairment o 04 Wheelchair user/mobility difficulties o 05 Personal care support

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
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School of Health Sciences

Notification of Tuition Fees Payable (This is not a VAT invoice)

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 ...............................................................................

2. o

Contact Name .............................................................................. Company Address Postcode

.................................................................................................................................................................................. .................................................................................................................................................................................. ................................................... Telephone Number .......................................................................................... Date ....................................................................

Students Signature .....................................................................................

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) ......................

Cardholders Signature ..................................................................................................

Date ....................................................

For Finance Use Only


Student Number Name SITS Course Code Fee Payable Date Financial Arrangements Approved by: Cost Centre/Internal Order
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Course/Module Code G/L Account Code

Start Date

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