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
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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
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3. Passport number
Please ensure before you apply that your passport is valid six months beyond the end date of your
elective.
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Passport number xxx
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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
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6. 1st Preference: Specialty
A&E
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7. 1st Preference: Number of weeks (minimum 4/maximum 8)
4
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8. 1st Preference: Start date requested (DD/MM/YYY)
The start date must fall within a block date.
05/09/2016
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9. 2nd Preference: Speciality
Dermatology
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10. 2nd Preference: Preferred Campus
Royal Free
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11. 2nd Preference: Number of weeks (minimum 4/maximum 8)
5
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12. 2nd Preference: Start Date (DD/MM/YYYY)
The start date must fall within a block date.
12/09/2016
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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
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