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The Language Centre,University College Cork
STUDY / WORK PROGRAMME2013/2014
REGISTRATION FORMPersonal Details
First Name(s): ________________________________________
Family Name: ________________________________________
Address for Correspondence:
Home Address (if not the same as above address):
________________________________________________________________________________
Date of Birth: _____/_____/_____ Telephone No: _________________________
Male or Female. _____________________ Nationality: ___________________________
First Language: ______________________ Second Language ______________________
Mobile. No. ___________________________ E-mail: _______________________________
Do we have your permission to use your e-mail and/or mobile no. for publicity in the future: Yes/No (please circle one)
Course Start Date: __________________ [Monday]
Host family RequestYes NoStart Date ______________________ Depart Date ______________________ No. Weeks ______
Registration Form mustbe accompanied bytwo passport size
PHOTOGRAPHS for a Student ID Card and file.
Scanned photos will not be accepted.
Level of English (please circle one): Elementary Lower Intermediate Intermediate Upper Intermediate Advanced Proficiency
Please summarise in no more than 20 words your main needs in English:
Where did you hear/read about this course:________________________________________Agent Agent Name _______________________Your university Name of University __________________________Web SiteOther studentPlease give details e.g. name of website: ____________________________________________
REGISTRATION CHECKLIST1. Send completed Application Form + Educational History + Proof of current English level
e.g. IELTS result, Cambridge Certificate, OR, complete the attached composition.2. Attach two passport size photographs.3 Full fees must be paid in advance of course start date (if your Application is approved). [please email [email protected] when you have paid Fees]4. A deposit (non-refundable) of €250.00 must be paid when an offer of a place is made.Fees can be paid by (international) bank draft drawn on a Irish bank and made payable to “Language Centre, UCC” or by lodging monies directly into the Language Centre UCC account (details below) or by credit/debit card (e-mail [email protected] for details). We do not accept personal cheques as payment. Places will be allocated on a first-come first-served basis. Minimum numbers are required to form a class, if minimum numbers are not met we reserve
the right to transfer students to a combination of other classes suited to their level, if it is possible, otherwise a refund will issue.
Bank Details : Bank Name: Bank of Ireland, 32 South Mall, Cork, Ireland Account Name: UCC Language Centre Account Number: 87099989 Sort Code: 90-27-68 IBAN Number: IE58 BOFI 9027 6887 0999 89 Bank Identifier Code: BOFIIE2D All bank charges to be paid by student.Completed Application Forms should be returned to:
The Language Centre (English as a Foreign Language), O’Rahilly Building, University College Cork, Cork, Ireland. Please mark envelope “Intensive Programme”.
If you have a query on your application, please send an e-mail to: [email protected]: +353 21 4902043 or 4902898 Web: www.ucc.ie/esol
For Office Use OnlyAmount Received: ________ Receipt number: _____________ Date: _____________
Amount Received: ________ Receipt number: ______________ Date: _____________
Total Cost of Course: €5,000Date acknowledgement letter sent: __________________________________________________
Date Acceptance details sent to student: _______________________________________________Comments:____________________________________________________________________
