<p> University College Cork Student Exchange Programmes</p><p>Application Form 2016-2017</p><p>Return completed form no later than 5.00pm, Friday, February 12th 2016 to:</p><p>Marita Foster, International Office, Roseleigh, Western Road, University College Cork</p><p>Please complete form in BLOCK CAPITALS</p><p>1 Personal Details</p><p>Surname </p><p>First Name</p><p>Date of Birth Male: Female: DD/MM/YY</p><p>2 Contact Details</p><p>Address for correspondence</p><p>T M e o l b e il p e h N o o n . e N o .</p><p>International Office, UCC Page 1 of 6 E m a il A d d r e s s</p><p>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.</p><p>3 Academic Information</p><p>Degree course currently registered for</p><p>State Examination Results to date (e.g. 2nd Class Honours in First Year etc.)</p><p>Name of Academic Staff Member from whom you have requested a statement of support</p><p>4 Universities/Colleges You may apply for all colleges/universities provided you meet the application criteria Please indicate your preferences in numerical order</p><p> a United States of America</p><p>Preferences</p><p>Boston College </p><p>Drexel University, Pennsylvania</p><p>Illinois Institute of Technology, Chicago</p><p>Juniata College, Pennsylvania</p><p>North Carolina State University at Raleigh</p><p>Oregon University System (OSU)</p><p>Salve Regina University, Rhode Island</p><p>St. Norbert College, Wisconsin</p><p>State University of New York at Cortland</p><p>University of Maine</p><p>International Office, UCC Page 2 of 6 University of Massachusetts at Amherst </p><p>University of Montana </p><p>University of Oklahoma</p><p>Washington College, Maryland</p><p> b MAUI-Utrecht Exchange</p><p>Baylor University</p><p>Kansas State University</p><p>Oklahoma State</p><p>Southern Illinois University at Carbondale</p><p>Texas State University San Marcos</p><p>Texas Tech University</p><p>Missouri University of Science and Technology</p><p>University of Missouri Columbia</p><p>University of Kansas</p><p>University of Missouri Kansas City</p><p>University of Missouri St Louis</p><p>University of Nebraska Kearney</p><p>University of Nebraska Lincoln</p><p>University of Nebraska Omaha</p><p>University of Oklahoma</p><p> c Canada</p><p>Saint Mary’s University, Nova Scotia</p><p>Concordia University, Montreal</p><p> d Singapore</p><p>Nanyang Technological University</p><p>National University of Singapore (SEFS students only)</p><p>5 Declaration I affirm that the particulars given in relation to this application are in all respects true.</p><p>International Office, UCC Page 3 of 6 Signature Date</p><p>6 Personal Statement</p><p>Please outline your reasons for applying to participate in this (these) study abroad exchange(s)</p><p>International Office, UCC Page 4 of 6 7 Statement of support from academic staff member</p><p>Please outline your reasons for supporting this application. Please return to Marita Foster, International Office, by Friday, February 12th 2016.</p><p>International Office, UCC Page 5 of 6 Signature Date</p><p>International Office, UCC Page 6 of 6</p>