Section 1

Student details

(You must complete this section accurately otherwise your visa application may be affected)

Title (Mr/Mrs/Ms)

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Family name (*)

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First given name (*)

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Second given name

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Preferred name

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Name as written on passport (*)

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Passport number (*)

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Passport expiry date (dd/mm/yy) (*)

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Gender (*)
MF
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Current age

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Date of birth (dd/mm/yy) (*)

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Country of birth (*)

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Student’s nationality (must be completed, necessary for visa application) (*)

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Country of residence (*)

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Address in country of residence (you must complete this accurately as it may affect your visa application) (*)

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Postcode (*)

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Country (*)

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Telephone and fax numbers in country of residence (inc. intl. code)

Tel

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Fax

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Mobile telephone (inc. intl. code)

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Email address (*)

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Contact email (if different from above)

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Contact address (if different from above)

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Postcode

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Country

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What type of visa do you intend to apply for? (*)
Adult student visa
Student visitor visa
No visa

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Section 2

Parent/guardian or sponsor details

Information we need to send financial information and reports

Title (Mr/Mrs/Ms)

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Family name

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Other names

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Relationship to student

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Home/contact address

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Postcode

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Country

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Telephone (inc. intl. code)

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Fax

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Mobile (inc. intl. code)

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Email address

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Section 3

INTO course selection

Study Abroad with English
Apr 2010
Jul 2010
Sep 2010
Jan 2011
Apr 2011
Jul 2011

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Start date (dd/mm/yy)

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End date (dd/mm/yy)

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Please specify number of terms (1 term minimum)

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Desired subject area for study

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English for Undergraduate Study
Sep 2010
Jan 2011
Apr 2011
Jul 2011

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Start date (dd/mm/yy)

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End date (dd/mm/yy)

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Please specify number of terms (1 term minimum)

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English for Postgraduate Study
Sep 2010
Jan 2011
Apr 2011
Jul 2011

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Start date (dd/mm/yy)

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End date (dd/mm/yy)

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Please specify number of terms (1 term minimum)

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Pre-Sessional English
Jun (12 weeks)
Jul (8 weeks)
Aug (4 weeks)

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Year of study (*)
20102011
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Academic programmes

Foundation pathways (*)
Foundation pathway in Business, Humanities and Social Sciences
Foundation pathway in Sciences, Engineering, Computing and Mathematics


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Sep 2010Jan 2011Sep 2011
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Graduate Diploma
Management
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Sep 2010
Jan 2011
Jan 2011

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Proposed undergraduate or postgraduate programme

(Must be completed for visa purposes)

Do you intend to study an undergraduate or postgraduate programme after completing your INTO course(s)?
YesNo
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Proposed undergraduate or postgraduate programme

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If you have applied to Queen's University Belfast please provide your reference number

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English preparation for Foundation students
Sep 2010
Jan 2011
Apr 2011
Jun 2011

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Start date (dd/mm/yy)

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End date (dd/mm/yy)

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Other applications

Have you applied to another INTO Centre(s)? (*)
YesNo
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If yes, which Centre(s) (please list in order of preference)

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If yes, which course(s)

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Section 4

Student’s education history

Please give details of your current or most recent school, college or university. Please ensure official institution transcripts, latest available results or forecast results are attached in English.

Institution name

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Dates of study-Start date (dd/mm/yy)

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End date or date achieved

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Date you received [or will receive] your certificate

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Highest educational qualification name

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Language of instruction

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Institution address

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Postcode

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Country

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Telephone (inc. int. code)

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Fax

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Email address

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Section 5

Student’s work experience (to be completed by students applying for Postgraduate study only)

Please give basic details of your current or most recent work experience. Where work experience constitutes a major part of the application, ensure an up-to-date resumé (CV) is attached in English.

Employer name

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Dates of employment

Start date (dd/mm/yy)

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End date (dd/mm/yy)

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Job title

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Main responsibilities

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Employer address

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Postcode

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Country

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Telephone (inc. int. code)

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Fax

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Email address

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Section 6

Current English language proficiency

Please tick and enter details of your most recent English language test. Note: Students will also be assessed upon arrival and study plans WILL be altered if there is any discrepancy.

IELTS overall score/grade

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Date test taken (dd/mm/yy)

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IELTS writing score for above test:

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IELTS TRF Number

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TOEFL overall score/grade

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Date test taken (dd/mm/yy)

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TOEFL writing score/grade

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Date test taken (dd/mm/yy)

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TOEFL registration number

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INTO overall score/grade

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Date test taken (dd/mm/yy)

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INTO writing score/grade

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Date test taken (dd/mm/yy)

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Other score/grade

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Date test taken (dd/mm/yy)

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Have you arranged to take any other English language test(s) before starting your INTO course? (*)
YesNo
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Name of Exam

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Date due to be taken (dd/mm/yy)

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If you want to study on an English course, please give details of where and how long you have studied English:

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How would you describe your current level of English? (*)
None
Basic
Elementary
Lower intermediate
Upper intermediate
Advanced

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Section 7

Sponsorship

How do you intend to fund your studies? (*)
Self
Family
Employer*
Sponsor*

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*Name of employer/sponsor:

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Section 8

Student goals

Please select which one or more of the following best describes your reason for wishing to study English at INTO Queen's University Belfast.
I have applied for an INTO Foundation, Diploma or Graduate Diploma course, and need to meet the English language entry requirement.
I need to improve my IELTS score
I plan to study a degree at Queen's University Belfast
I plan to attend another university in the UK
I want to experience life in a UK university
I need to improve my English for my current job or future employment
I want to experience British culture
I am studying English for my own personal development
Other reason

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If ‘Other’ please specify:

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Section 9

Accommodation and welfare

Accommodation will be reserved and confirmed when full payment of tuition and accommodation fees has been received. Please note it is a condition that a minimum of one full term’s notice (university residence) or four weeks’ notice (homestay) is required if you wish to leave or change your accommodation. During the academic year University residence accommodation is available only if you enrol on a fixed term start date and for multiples of one term, excluding holidays.

Please select one option and complete as appropriate

University residential accommodation

Tick below which option you require
Ensuite room, no meals
Ensuite room, with meal plan

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Do you require a bedding pack to be provided? (Cost per bedding pack is £30)
YesNo
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Do you envisage that you will have any specific requirements in student accommodation as a result of a disability/medical condition? (*)
YesNo
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If yes please state:
Wheelchair accessible
Ground floor room
Flashing fire alarm
Vibrating pillow
Other please specify

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Other please specify

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I do not require any accommodation

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Students who are under 18

INTO recommends that parents appoint a UK-based guardian for international students under 18. INTO can supply a list of Guardianship providers on request.

If parents are making their own arrangements for either Guardianship services, or if a friend or family member in the UK is to act as guardian to the student, please provide the details below:

Name of guardian

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Relationship to student

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Address of guardian

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Postcode

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Country

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Email address

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I confirm that the guardian is over 21 years of age.
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Dietary requirements
Please give details of special dietary requirements e.g.: halal, vegetarian, no pork, any food allergies.

Do you have any medical conditions? (*)
YesNo
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Medical information
Please give details of any medical conditions, disabilities or allergies that require attention or notification and any prescribed medicine taken on a regular basis
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Completion and signing of this form gives INTO permission to administer first aid by trained staff first aiders if required.

Do you consider yourself to have a disability? If yes please specify

(*)
A. No disability
B. You have a social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder
C. You are blind or have a serious visual impairment uncorrected by glasses
D. You are deaf or have a serious hearing impairment
E. You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease or epilepsy
F. You have a mental health condition, such as depression, schizophrenia or anxiety disorder
G. You have a specific learning disability such as dyslexia, dyspraxia or AD(H)D
H. You have physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
I. You have a disability, impairment or medical condition that is not listed above
J. You have two or more impairments and/or disabling medical conditions

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Please provide further details of the nature of your disability and the support you may require should you attend the University. (Please note that some support mechanisms may take considerable time to organise. For example books in Braille or changes to buildings. It is therefore important that you provide as much as possible.)

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INTO Queen's University Belfast will ensure that all personal data disclosed will only be used to plan appropriate support for you. It may be necessary for INTO Queen's University Belfast to disclose appropriate and relevant details to some University departments to facilitate this process.

(*)
I consent to information relating to my personal details, nature of disability and academic and support requirements being forwarded as outlined above.
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Criminal offences
Please tick here If you have been convicted of a criminal offence and supply details on a separate sheet.
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Travel and medical insurance

The full cost of Uniplan insurance will be added to the invoice unless proof of alternative adequate cover is attached.

Please state when you would like the insurance to start

Start date of insurance (dd/mm/yy)

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End date of insurance (dd/mm/yy)

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I have my own insurance and enclose a copy
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Airport pick-up

Students MUST arrive on the Saturday or Sunday prior to the start of the course. Flight details including arrival date and flight number should be sent to the INTO Admissions office as soon as possible in order that airport arrangements can be made. If you are under 18 you must either book an INTO airport pick-up or provide evidence of your arrangements. If an airport pick-up is required, this will be invoiced as an extra at confirmation stage and full payment must be received for an airport pick-up to be confirmed.

Do you require an airport pick-up (*)
YesNo
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Please indicate which airport
Belfast International Airport (£40)
Belfast City Airport (£25)

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Section 10

How did you hear of INTO Queen's University Belfast? (*)
British Council
Education Exhibition
Website*
Friend or relative
Education agent
Other*

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*Please state which website or other source

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If education agent, British Council or exhibition, which agent/organisation/event?

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Section 11

Form of indemnity

i) Background

This indemnity is to be signed by the Student, and also by his/her Parent or Legal Guardian if the Student is under eighteen years of age. Until this indemnity has been signed and returned to INTO, the Student may not take part in an excursion organised by INTO.

ii) Indemnity

In consideration of the Principal and/or Head Teacher and/or Director and/or any employee of INTO (which expression for the purposes of this indemnity means INTO UEA LLP and any relevant associated or connected organisation) agreeing to make arrangements for and to authorise INTO personnel to take me/my son/daughter/ward from time to time on expeditions outside the usual premises of INTO I hereby fully and effectively indemnify the said Principal and/or Head Teacher and/or Director and/or any employee (as the case may be) of INTO against:

a) any and all claims, losses, damages or costs incurred directly or indirectly which they or any of them may be or become liable to pay in consequence of any injury or damage to or illness of me/my said son/daughter/ward occurring during or as a result of any of the said expeditions

b) any and all claims, losses, damages or costs paid to or payable to or claimed by any third party which may be made against them or any of them in consequence of any act or default of me/my said son/daughter/ward during or as a result of any of the said expeditions

c) any and all other costs, claims, losses and expenses incurred directly or indirectly by them or any of them on behalf of me/my said son/daughter/ward during or as a result of any such expedition,

provided that this indemnity does not extend to any claims, damages, costs or expenses in respect of and to the extent to which INTO and member(s) of the staff or any of them are indemnified and recover under any policy of insurance. I authorise INTO to supply any relevant records to educational institutions, government bodies, parents, sponsors and educational agents if requested without notification.

SIGNED (Parent/guardian)

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Date (dd/mm/yy)

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SIGNED (Student)

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Date (dd/mm/yy)

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Section 12

Payment details

Once you have accepted an offer of place, you must send us a deposit of £1,000 and an accommodation deposit of £1,000 (if you have requested INTO accommodation).

You will also be required to pay in advance the Uniplan insurance fee unless you have provided proof of alternative cover.

Payment can be made either by sterling bankers draft, VISA, Mastercard, Maestro, Solo, Electron, Delta or by direct bank transfer. Our bank details are as follows:

Bank name: Barclays Bank PLC
Address: 5-7 Red Lion Street, Norwich NR1 3QH
Account name: INTO Queen's LLP
Sort code: 20-62-53
Account number: 23201996
SWIFT code: BARCGB22
IBAN number: GB45 BARC 2062 5323 2019 96

Section 13

Declaration

To be signed by the student and parent, sponsor or legal guardian (*)
I have read and understood all parts of this electronic application form and have completed all sections that relate to my application
I have read and understood the brochure and agree to abide by the Terms and Conditions
I agree to abide by the Cancellation and Refund Policy
I agree to pay all tuition and accommodation fees incurred by the student as they become due
I agree that my records and achievements may be used for promotional purposes, without further notification

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SIGNED (Parent/guardian)

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Date (dd/mm/yy)

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SIGNED (Student)

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Date (dd/mm/yy)

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Section 14

Application check list

I confirm that I have: (*)
completed the application form in full and checked for accuracy
enclosed proof of an alternative insurance policy, if appropriate
enclosed full transcripts of all my relevant qualifications (including English language level) translated into English

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Please list here all the transcripts you are enclosing: (Must be completed for visa purposes)

Academic transcripts

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English language transcripts

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