QM MODIFIED APPLICATION SCHEME

MBBS PROGRAMME 2014 entry

Surname

Title

Forenames (in full):

Home address:

Personal email address

Telephone

Contact address (if different from above)

_______________________________________________________________

Male / Female
_____________________
Current fee status

Date of birth __________________________ Nationality

UK / EU / Channel Islands / International

Proposed source of financial support

(including name of LEA if appropriate)
_________________________________________________________________

Course/s Applied for (Please circle):A100 (5 Year Medical

Degree)

A101 (4 Year Graduate

Entry Degree)

Both

Current University Course at Queen Mary:Degree (please

circle)
B990
HB18
HBC8
B890
B891

Year of
Entry

A levels or Equivalent:Date taken

Subject

Result

Subject

Result

GCSEs or Equivalent:Date taken

ENGLISH LANGUAGE QUALIFICATION (if not listed above)

Exam taken (ie IELTS, TOEFL)

Result

UKCAT
Date taken

Subject
Verbal Reasoning
Quantitative Reasoning
Abstract Reasoning
Decision Analysis

Result

Attach a copy of your official UKCAT result to your application form

PERSONAL STATEMENT

CONFIDENTIAL REFERENCE
Name of applicant
_____________________________________________________________________________

Signed _________________________________________________________________
Date___________________

Name of referee (in capitals)

_______________________________________________________________________
Position __________________________________________________ Institution
_____________________________
Address
________________________________________________________________________________________
Please return this to:
Natasha Chappell
Student Recruitment and Admissions Manager
Garrod Building
Barts and The London School of Medicine and Dentistry
Turner Street
London E1 2AD

The deadline for applications is 15 October 2012

Applicants signature: I confirm that the information given on this application is
complete and true.
Signed _____________________________________________________ Date
________________________________