Section 1
Student details
(You must complete this section accurately otherwise your visa application may be affected)
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| 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(*) |
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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) |
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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? |
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Section 2
Parent/guardian or sponsor details
Information we need to send financial information and reports
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| 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
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English language courses
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| Study Abroad with English |
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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 |
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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 |
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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 |
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Year of study
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Academic programmes
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Foundation
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| Foundation pathways in Business and Economics |
Foundation pathway in Humanities and Law |
Foundation pathways in the Sciences |
Foundation pathway in Computing Sciences |
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Foundation pathway in Mathematics and Actuarial Sciences
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Start date
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Diploma
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Start date
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Graduate Diploma
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Start date
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Newton Programme: A-levels at University
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Start date
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Proposed undergraduate or postgraduate programme
(Needs to be completed for visa purposes)
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Do you intend to study an undergraduate or postgraduate programme after completing your INTO course(s)?(*)
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Proposed undergraduate or postgraduate programme
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If you have applied to the University of East Anglia please provide your reference number
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Other applications
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Have you applied to another INTO Centre(s)?(*)
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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.
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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
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.
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Employer name
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Dates of employment
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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.
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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?(*)
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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?(*)
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Section 7
Sponsorship
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How do you intend to fund your studies?(*)
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*Name of employer/sponsor:
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Section 8
Student goals
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Please select which one or more of the following best describes your reason for wishing to study English at INTO University of East Anglia.
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If ‘Other’ please specify:
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Section 9
Accommodation and welfare
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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.
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Please select one option and complete as appropriate
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INTO Centre accommodation
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Do you require a bedding pack to be provided? (Cost per bedding pack is £25)
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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?
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If yes please state:
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Other please specify:
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Homestay
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Do you require homestay during the holiday periods?
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University residence (Pre-Sessional only)
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| Tick below which option you require |
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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.
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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:
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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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Dietary requirements
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Do you have any medical conditions?
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Medical information
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Do you consider yourself to have a disability? If yes please specify |
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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 University of East Anglia will ensure that all personal data disclosed will only be used to plan appropriate support for you. It may be necessary for INTO University of East Anglia to disclose appropriate and relevant details to some University departments to facilitate this process.
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Criminal offences
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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
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Start date of insurance (dd/mm/yy)
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End date of insurance (dd/mm/yy)
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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.
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Do you require an airport pick-up(*)
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Please indicate which airport
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Section 10
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How did you hear of INTO University of East Anglia?
(*)
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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
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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.
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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 12
Payment detail
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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 UEA LLP
Sort code: 20-62-53
Account number: 10041033
SWIFT code: BARCGB22
IBAN number: GB29 BARC 2062 5310 0410 33
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Section 13
Declaration
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(*)
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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
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I confirm that I have:
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Please list here all the transcripts you are enclosing: (Must be completed for visa purposes)
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Academic transcripts
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English language transcripts
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