The University of the West Indies s1

The University of the West Indies St. Augustine

Confirmation Receipt

Name (please print):______Programme of 1st Choice:______

DOCUMENTS SUBMITTED: The following documents are required. Please ensure that you submit these documents along with this signed page.

Birth Certificate Marriage Certificate (where applicable). Legal Affidavit or Deed Poll if present name is different from that on the Birth Certificate Academic Certificates (GCE, CXC (CAPE), CXC (CSEC)). GCE/CXC (CSEC/CAPE) Grade Slips (Accepted Only in cases where certificates are not yet available) Professional Certificate/Diploma Official transcripts [sent directly from granting Institution]. Autobiographical Statement (200 words)-Faculty of Medical Sciences –Mandatory TOEFL Examination Score (if English is not native language). TOEFL Score of 500 or greater. Supplemental Sheet 1 (if you are due to write examinations or are awaiting examination results) Supplemental Sheet 2 (for undergraduate applicants Bed Primary Education, BSc Human Ecology and Certificate of Specializations in Tropical Agriculture) Supplemental Sheet 3 Other (please specify) ______

DECLARATION I hereby certify that I have read and understood the instructions and the information necessary for completing this application and that all statements made are true and complete. I intend to provide such fees as may be payable to the University. I understand that otherwise my admission to or registration in the University may be revoked.

______/______/______Signature of Applicant Date (dd/mm/yyyy)

FOR OFFICIAL USE ONLY STATUS: Full-time Part-time Evening

OFFICIAL ASSESSMENT

Undergraduate applicants only:

Qualified D A O AU

Other Qualifications X Qualifying F QA OU QO

Refer for decision re Matriculation M Not Qualified U Re-entry R

NS Sponsored Contributing S Non Sponsored Contributing Non-Contributing NC

______/______/______Signature of University Officer Date (dd/mm/yyyy) The University of the West Indies St. Augustine

Supplemental Sheet 1

Academic Programmes or Examinations in Progress

List academic programmes or examinations for which you are currently preparing or awaiting examination results. Examining Body Level Subject/Programme Date of Exam Grade (e.g. CXC, CSEC, (dd/mm/yyyy) [official UWI) use only] The University of the West Indies St. Augustine

Specialisations

Applicants to the following programmes, please indicate which area you would like to specialize in:

BEd Primary Education Educational Administration Language Arts Mathematics Science Social Studies

BSc Human Ecology Nutrition & Dietetics Consumer Sciences

Certificate of Specializations in Tropical Agriculture: Agricultural Marketing Agribusiness Management Agro-environmental Management Rural Development, Communications & Education The University of the West Indies St. Augustine

Employment and Referee Information

Employment Information:

Please provide information on your entire work experience. This is particularly helpful in the case of mature applicants.

List employment information starting with your current job a) Name of Employer b) Name of Employer

Position Position

Address: Apt/Street/PO Box Address: Apt/Street/PO Box

City/Town/Post Office Parish/County City/Town/Post Office Parish/County

State Zip/Postal Code Country State Zip/Postal Code Country

From To From To _____/______/______/______/______/______/______/______/______c) Name of Employer d) Name of Employer

Position Position

From To From To _____/______/______/______/______/______/______/______/______

Referee Information

Certificate, Diploma and Mature Applicants must submit two(2) referee reports.

Name Two Referees (Certificate, Diploma & Mature Applicants for Associate Degrees only) (Recommendation from your employer must accompany application) a) Name of Referee b) Name of Referee

Name of Organization Name of Organization

Position Position

Telephone Number Fax Number Email Address Telephone Number Fax Number Email Address ( ) - ( ) - ( ) - ( ) -