<p> The University of the West Indies St. Augustine</p><p>Confirmation Receipt</p><p>Name (please print):______Programme of 1st Choice:______</p><p>DOCUMENTS SUBMITTED: The following documents are required. Please ensure that you submit these documents along with this signed page.</p><p>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) ______</p><p>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.</p><p>______/______/______Signature of Applicant Date (dd/mm/yyyy)</p><p>FOR OFFICIAL USE ONLY STATUS: Full-time Part-time Evening</p><p>OFFICIAL ASSESSMENT</p><p>Undergraduate applicants only:</p><p>Qualified D A O AU</p><p>Other Qualifications X Qualifying F QA OU QO</p><p>Refer for decision re Matriculation M Not Qualified U Re-entry R</p><p>NS Sponsored Contributing S Non Sponsored Contributing Non-Contributing NC</p><p>______/______/______Signature of University Officer Date (dd/mm/yyyy) The University of the West Indies St. Augustine</p><p>Supplemental Sheet 1</p><p>Academic Programmes or Examinations in Progress</p><p>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</p><p>Supplemental Sheet 2</p><p>Specialisations</p><p>Applicants to the following programmes, please indicate which area you would like to specialize in:</p><p>BEd Primary Education Educational Administration Language Arts Mathematics Science Social Studies</p><p>BSc Human Ecology Nutrition & Dietetics Consumer Sciences</p><p>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</p><p>Supplemental Sheet 3</p><p>Employment and Referee Information</p><p>Employment Information:</p><p>Please provide information on your entire work experience. This is particularly helpful in the case of mature applicants.</p><p>List employment information starting with your current job a) Name of Employer b) Name of Employer</p><p>Position Position</p><p>Address: Apt/Street/PO Box Address: Apt/Street/PO Box</p><p>City/Town/Post Office Parish/County City/Town/Post Office Parish/County</p><p>State Zip/Postal Code Country State Zip/Postal Code Country</p><p>From To From To _____/______/______/______/______/______/______/______/______c) Name of Employer d) Name of Employer</p><p>Position Position</p><p>Address: Apt/Street/PO Box Address: Apt/Street/PO Box</p><p>City/Town/Post Office Parish/County City/Town/Post Office Parish/County</p><p>State Zip/Postal Code Country State Zip/Postal Code Country</p><p>From To From To _____/______/______/______/______/______/______/______/______</p><p>Referee Information</p><p>Certificate, Diploma and Mature Applicants must submit two(2) referee reports.</p><p>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</p><p>Name of Organization Name of Organization</p><p>Position Position</p><p>Address: Apt/Street/PO Box Address: Apt/Street/PO Box</p><p>City/Town/Post Office Parish/County City/Town/Post Office Parish/County</p><p>State Zip/Postal Code Country State Zip/Postal Code Country</p><p>Telephone Number Fax Number Email Address Telephone Number Fax Number Email Address ( ) - ( ) - ( ) - ( ) -</p>