Liverpool School of Tropical Medicine

APPLICATION FORM
Personal Details:
Title – Dr/Mrs/Mr/Miss/Other: Surname/Family Name:

First Name: Middle Name:

Date of Birth: Nationality:

Passport Number: Country of Residence:

Previous Last Name (if applicable): Male/Female:

Permanent Address: Address for Correspondence (if different)

Telephone No. Telephone No.

Mobile No: Email address:

Programme Application Details:

Programme Title: Diploma in Humanitarian Assistance, South Africa.
Proposed Start Date: 19th April 2010 – 28th May 2010
The programme includes a choice of options, please indicate your preference here:

Health in Emergencies
Technical Support
Policy and Advocacy

Academic Qualifications: (please attach copies of certificates)

University/Institution Attended:

Degree Title (Subject):

Qualification Gained (BSc / Certificate / Diploma):

Dates of Attendance DD/MM/YYYY From: To:

Date of Award DD/MM/YYYY:

Professional Qualifications: (please attach copies of certificates)
Please give details of any additional professional or other qualifications

Employment History: (if applicable)

Position Held Dates Employer & Brief Description of Responsibilities
Country

(Please continue on a separate sheet if necessary)

English Language Qualifications: (for applicants whose first language is not English)
We require a minimum score of 6.5 for the IELTS or in the TOEFL examination, 570
for the paper-based test OR 88 in the iBT test.
IELTS Score Date Taken

TOEFL Score Date Taken

Other Score/Grade Date Taken

Computer Skills:

Other Relevant Skills and Experience:

Future plans (what do you intend to do after completing this programme?):

Disability/ special needs:

Do you have a disability?

Yes/ No

Please also complete the Equal Opportunities Monitoring form attached. Any information about your
disability will be treated in confidence.

Criminal Convictions:

Do you have any criminal convictions?

(If you do not answer this question we cannot process your application)

Yes No

If you have answered yes, please give details of the conviction in terms of sentence
served or caution received.

*Referees: (separate form attached)

NB. Applicants are requested to ask their referees to e-mail, post or fax references directly
to the Programme Administrator as soon as possible. References by e-mail should be
followed by a signed copy by post / fax.

Name Name

Position Position

Address Address

Email Email

Telephone No. Telephone No.

* Note concerning referees: Referees should be Senior Academic and/or Professional

persons who are currently responsible, or have recently been responsible, for supervising
you. Close personal friends and family are not acceptable as referees.

Referees should be Senior Academic and/or Professional persons who are currently responsible,
or have recently been responsible, for supervising you.
Personal Statement: (Please give details of why you applied for the programme and
what you expect to gain from attending the programme)

Financial Support/Sponsorship
• Candidates must provide evidence that they will have sufficient funds available for
their fees and maintenance during the programme. If self-funded, please enclose a
recent bank statement.

• If sponsored please state the name of authority responsible for payment of tuition
fees and enclose written confirmation from sponsors.

• Please note that family member sponsorship is classified as self-funding, and the
requirements for self-funded students apply.

1. Self-funded: Yes / No. If YES, please enclose a recent Bank Statement.

2. Sponsored: Yes / No. If YES, please complete the questions below:

Have you applied for a scholarship / sponsorship: Yes / No

If ‘yes’, please state name and address of funding body:

Have you received a scholarship / sponsorship offer: Yes / No

If ‘Yes’, please enclose a copy of your offer letter.
If ‘No’, please state the date by which you expect to have received an offer:
Please ensure that you notify the Programme Administrator and forward a copy of your
offer letter as soon as it becomes available.
Please indicate where you first heard about the programme: Please tick one box

University Prospectus

Supervisor

Education Exhibition/Careers Fair Venue …………………………………..................

WWW Please specify ………………………………………

Professional Journal Please specify ………………………………………

Alumni/Previous LSTM Student

Friends/Relatives

Other Please specify ………………………………………

Application forms may be e-mailed or faxed:

Fax: 0044 151 705 3347

Eleanor Carr: e.carr@liverpool.ac.uk Telephone: 0044 151 705 3359

Alternatively, applications can be posted to:

(Programme Administrator)
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool
L3 5QA, UK

Check-list

Evidence of academic or professional qualifications

(including transcripts where necessary)

Copies of English language certificates (where appropriate)

IELTS / TOEFL / WAEC

Evidence of funding.

Family member sponsorship is classified as self funding. If a family member is

responsible for your fees and living expenses, a bank statement or letter from the bank
is required along with a supporting letter.

Passport photographs x 2 (with name on reverse)

If you have sent your application via e-mail, a jpeg photograph is acceptable

I have forwarded the reference forms to two referees

Previous Last Name: If you have mentioned a change in name, please provide
supporting evidence to support this e.g. marriage certificate.

Other relevant items (please specify)

Completed Equal Opportunities Monitoring Form

Equal Opportunities Monitoring
In order for us to monitor equal opportunities, we would appreciate it if you would answer the following
questions.

1. Ethnic Origin

White British 11 Chinese 34

White Irish 12 Other Asian Background 39
White Scottish 13
Irish Traveller 14
Other white background 19 Mixed – White and Black Caribbean 41
Mixed – White and Black African 42
Black or Black British – Caribbean 21 Mixed – White and Asian 43
Black or Black British – African 22 Other Mixed background 49
Other Black Background 29 Other Ethnic Background 80

Asian or Asian British – Indian 31 Not Known 90

Asian or Asian British – Pakistani 32
Asian or Asian British – Bangladeshi 33 Information Refused 98

…………………………………………………………………………………………………………..................................................

2. Disability .

In the application form we have asked about any disability/ special needs in order that we can provide
students with the best support.

For planning purposes we would appreciate it if you could identify the most appropriate description to
describe your disability, and enter the corresponding number in the above box.

Disabilities / Support Required

0 You do not have a disability or are not aware of any additional support requirements in study or
accommodation

1 You have a specific learning difficulty (e.g. Dyslexia)

2 You are blind / partially sighted

3 You are deaf / hard of hearing

4 You are a wheelchair user / have mobility difficulties

5 You have Autistic Spectrum Disorder or Asperger’s Syndrome

6 You have mental health difficulties

7 You have an unseen disability, e.g. diabetes, epilepsy, or a heart condition

8 You have two or more of the above difficulties / special needs

9 You have a disability, special need or medical condition not listed above

If you would like to discuss support, access and facilities for disabled people, please contact The Welfare
and Accommodation Officer.

Rebecca Riley
0151 705 3176
rriley@liv.ac.uk