Please Complete Form in BLOCK CAPITALS

University College Cork Student Exchange Programmes

Application Form 2016-2017

Return completed form no later than 5.00pm, Friday, February 12th 2016 to:

Marita Foster, International Office, Roseleigh, Western Road, University College Cork

Please complete form in BLOCK CAPITALS

1 Personal Details

Surname

First Name

Date of Birth Male: Female: DD/MM/YY

2 Contact Details

Address for correspondence

T M e o l b e il p e h N o o n . e N o .

International Office, UCC Page 1 of 6 E m a il A d d r e s s

Please print email address in BLOCK CAPITALS. It is very important to provide an accurate email address as it will be used for correspondence during the application process.

3 Academic Information

Degree course currently registered for

State Examination Results to date (e.g. 2nd Class Honours in First Year etc.)

Name of Academic Staff Member from whom you have requested a statement of support

4 Universities/Colleges You may apply for all colleges/universities provided you meet the application criteria Please indicate your preferences in numerical order

a United States of America

Preferences

Boston College

Drexel University, Pennsylvania

Illinois Institute of Technology, Chicago

Juniata College, Pennsylvania

North Carolina State University at Raleigh

Oregon University System (OSU)

Salve Regina University, Rhode Island

St. Norbert College, Wisconsin

State University of New York at Cortland

University of Maine

International Office, UCC Page 2 of 6 University of Massachusetts at Amherst

University of Montana

University of Oklahoma

Washington College, Maryland

b MAUI-Utrecht Exchange

Baylor University

Kansas State University

Oklahoma State

Southern Illinois University at Carbondale

Texas State University San Marcos

Texas Tech University

Missouri University of Science and Technology

University of Missouri Columbia

University of Kansas

University of Missouri Kansas City

University of Missouri St Louis

University of Nebraska Kearney

University of Nebraska Lincoln

University of Nebraska Omaha

University of Oklahoma

c Canada

Saint Mary’s University, Nova Scotia

Concordia University, Montreal

d Singapore

Nanyang Technological University

National University of Singapore (SEFS students only)

5 Declaration I affirm that the particulars given in relation to this application are in all respects true.

International Office, UCC Page 3 of 6 Signature Date

6 Personal Statement

Please outline your reasons for applying to participate in this (these) study abroad exchange(s)

International Office, UCC Page 4 of 6 7 Statement of support from academic staff member

Please outline your reasons for supporting this application. Please return to Marita Foster, International Office, by Friday, February 12th 2016.

International Office, UCC Page 5 of 6 Signature Date

International Office, UCC Page 6 of 6