2/17/2016 Opinio Respondent 1423186 [pr int] Single response: 2016-17 Block 1 Example Respondent id: 1423186 Start date: 2/17/16 1:46 PM Completed date: 2/17/16 1:46 PM Response language: English [en] 1. Personal Details Title M s/M r/M rs Surname (as on passport) xxx Forename (as on passport) xxx Date of Birth (dd/mm/yyyy) 01/01/2016 Nationality xxx Country of birth xxx Contact Address xxx Postcode xxx Contact Telephone No. xxx Email xxx@xxx.com Emergency contact name xxx Emergency phone number xxx Home Institution xxx Expected degree & date of award xxx Current year of study xxx 2/17/16 1:46:25 PM GMT 2. Do you need a visa to study in the UK? NB: Non-EU/UK passport holders will require a Tier 4 visa. Queries about visas should be directed to the UK Borders Agency http://www.ukba.homeoffice.gov.uk/aboutus/contact/contactspage/visaservices/ 2. No 2/17/16 1:46:25 PM GMT 3. Passport number Please ensure before you apply that your passport is valid six months beyond the end date of your elective. https://opinio.ucl.ac.uk/admin/responses.do;jsessionid=ED430C86A05933A16C55CCD3B0A67CEE?action=viewSingleResponse&surveyId=42131&respon… 1/3 2/17/2016 Opinio Passport number xxx 2/17/16 1:46:25 PM GMT 4. Please provide confirmation of a level of spoken and written English – please upload the relevant document as a jpg format. If this is not possible then please email medsch.visitingelectives@ucl.ac.uk a PDF to show confirmation of a level of spoken and written English. 5. 1st Preference: Preferred Campus UCLH 2/17/16 1:46:35 PM GMT 6. 1st Preference: Specialty A&E 2/17/16 1:46:35 PM GMT 7. 1st Preference: Number of weeks (minimum 4/maximum 8) 4 2/17/16 1:46:35 PM GMT 8. 1st Preference: Start date requested (DD/MM/YYY) The start date must fall within a block date. 05/09/2016 2/17/16 1:46:35 PM GMT 9. 2nd Preference: Speciality Dermatology 2/17/16 1:46:44 PM GMT 10. 2nd Preference: Preferred Campus Royal Free 2/17/16 1:46:44 PM GMT https://opinio.ucl.ac.uk/admin/responses.do;jsessionid=ED430C86A05933A16C55CCD3B0A67CEE?action=viewSingleResponse&surveyId=42131&respon… 2/3 2/17/2016 Opinio 11. 2nd Preference: Number of weeks (minimum 4/maximum 8) 5 2/17/16 1:46:44 PM GMT 12. 2nd Preference: Start Date (DD/MM/YYYY) The start date must fall within a block date. 12/09/2016 2/17/16 1:46:44 PM GMT 13. I have read and understood all the application materials and conditions for Visiting Electives on the UCL Medical School website at: http://www.ucl.ac.uk/medicalschool/undergraduate/electives. I understand that acceptance of an Elective place is on the understanding that I abide by all regulations in place at UCL and all the conditions set out on the Visiting Electives website. I confirm that all information given in this application is accurate and true. 1. I agree 2/17/16 1:46:47 PM GMT https://opinio.ucl.ac.uk/admin/responses.do;jsessionid=ED430C86A05933A16C55CCD3B0A67CEE?action=viewSingleResponse&surveyId=42131&respon… 3/3