Doctoral Programme in Clinical Psychology Application Form
Please complete this form with reference to the notes provided ’Notes for Applicants 2016’
Return 10 copies with a non-returnable application fee of €50
(online payment instructions in notes please use the link provided).
Completed applications should be returned to:
Muriel Keegan, Course Administrator, Doctoral Programme in Clinical Psychology,
Room G218 School of Psychology, Newman Building, Belfield, Dublin 4.
Insert or Scan a passport
size photo here please
This application form must be returned on or before 5.00p.m. Friday 5th February 2016
Enquiries about the course should be addressed to the Course Administrator at
+353-1-7168120 or by e-mail at Muriel.keegan@ucd.ie
Personal Information
Name
Home Address
Home Phone Number
Mobile Phone Number
E-mail Address (1)
E-mail Address (2)
Age:
Date of Birth
Referee Information
Referee 1: Academic
Name and address:
Phone Number:
E-mail Address:
Referee 2: Employer
Name and address:
Phone Number:
E-mail Address:
Please ensure you have included the following with your application
√
1.
Application Fee - Date of Payment:
2.
10 copies of this application form (a clear passport size photo must be included on all 10 copies)
4.
A course transcript from the universities where you obtained your academic qualifications, if you have not
studied at UCD previously
5.
A photocopy of your birth certificate or passport, if you have not studied at UCD previously
6.
Your student number, if you are a past student of UCD
I declare that the information given in this application is true and accurate.
Signature of Applicant
Date
1
1. Sponsorship preferences – contingent on availability for the Programme 2016-2019.
Please indicate your sponsoring preferences by placing the number 1 beside your first preference, the number 2 beside your
second preference, the number 3 beside your third preference (and so on). Information on sponsoring agencies is available at
their website. If you are offered a place on the course, and sponsorship, you will be required to complete most of your
placements in your sponsoring agency and to be available to spend 3 years after graduation working in that agency.
Please also see section 1 of Notes for Applicants 2016.
Agency
Website
Preference No
(1 or 2)
HSE Dublin Mid Leinster Area
http://www.hse.ie
Longford/Westmeath
HSE Dublin Mid Leinster Area
http://www.hse.ie
Laois/Offaly
HSE Dublin North East Area
http://www.hse.ie
Louth & Meath
HSE Southern Area (South East Region)
http://www.hse.ie
i.e. Waterford
Explain your sponsorship preferences in 50 words:
Alternative Funding Routes for EU and Non-EU Students :
I am an international student and have Non-EU
Governmental or other Institutional funding to support
my application:
Yes
No
Please Provide Details:
I am an international student and have self-funding to
support my application
Yes
No
Please Provide Details:
I am an EU student and in the event traditional
sponsorship is unavailable for the 2016 intake would
consider self-funding (your response will not affect your
application to a traditional sponsored place). Financial
support may be available through graduate student bank
loans – please see notes).
Yes
No
2
2. Secondary Education exam results (Leaving Certificate, A level results, or equivalent)
Dates
From
To
Name of school
Exams Taken
Level
H/0
Results
Grade
Points
1.
2.
3.
4.
5.
6.
What are your total points (or average percentage for A level). International applicants please indicate your GPA.
Exam
%
If English is not your first language, specify results in oral and written exams taken
to evaluate competence in using the English language, i.e. TOFEL
3. Undergraduate university education in Psychology (BA, BSc, H Dip Psych)
Dates
From
To
Name of University
Degree
Level of Award
%
Tick the box opposite if your degree confers eligibility for graduate registration with the Psychological
Society of Ireland.
Tick the box opposite to indicate that you have included a photocopy of your course transcript and a
photocopy of your birth certificate or passport if you received your degree from a college other than UCD
If you have previously attended UCD please give your Student Number
4. Postgraduate university education in Psychology (MA, MSc, MPsychSc, M Phil, PhD, D Phil)
Dates
From
To
Name of University
Degree
Indicate the proportion of the programme (s) that involved
coursework, placement and research
Coursework
Level of Award
Placement
%
Research
If you are undertaking a research degree such as an M Litt or PhD, when do you expect to graduate
Tick the box opposite to indicate that you have included a photocopy or your course transcript and a
photocopy of your birth certificate if you received your degree from a college other than UCD
If you have previously attended UCD please give your Student Number
3
5. Other relevant professional training experiences (including workshops, certificates, diplomas or
qualifications)
200 words max
6. Relevant research experience (including undergraduate project research experience, graduate
research experience, clinical research assistant experience, computing skills & qualifications, statistics
qualifications, theses, presentations, publications, & technical reports)
500 words max
4
7. Relevant clinical work experience. (Please list from most recent.
Append additional page if necessary)
From
To
Employer’s name
and address
Post held
Hours
per
week
Paid or
unpaid
Responsibilities and competencies
developed in post
(50 words max per post)
8. Outline in no more than 300 words your reasons for applying for clinical training and any other
information that you consider relevant to your application.
300 Words max
5