SCHOOL OF MEDICINE & MEDICAL SCIENCE
PhD STUDENT APPLICATION FOR REGISTRATION
SECTION 1 :( To be completed by the applicant)
Personal Details:
Title
Last name
Date of Birth (dd/mm/yyyy)
First name
Gender
Country of Birth
Country of Citizenship
Mothers Maiden Name
Permanent Address:
Contact Telephone
number:
Email Address:
Address for
correspondence
(If different, to above please give dates)
First language:
Second language
UCD student number
(If applicable)
Qualifications:
1
Qualification:
Standard
Obtained:
Awarding
Institute:
Date of
attendance:
Date of Award:
Qualification 2(If applicable):
Qualification:
Standard
Obtained:
Awarding
Institute:
Date of
attendance:
Date of Award:
Proposed degree of study (Full or Part Time):
PhD research F/T
PhD research P/T
Start / Registration Date:
May 2015
September 2015
January 2016
2
Thematic Programme: (if applicable - Translational Medicine; Infection Biology)
Title of Thematic Programme:
Subject Area of Degree: e.g. Diagnostic imaging; Vascular Biology; Medicine etc.:
Research Proposal:
Title of Project:
Include background to the project and outline the problem to be addressed. Include research
hypothesis, overall aims of the project and methodology to be used. Outline the novelty and significance
of the work proposed.
If your project involves a clinical trial please include details of the clinical design of the trial and your
specific role in the project.
3
SECTION 2 : (To be completed by the principal supervisor*)
*Please read the accompanying explanatory notes before completing this form
Principal Supervisor and Nominator:
Title:
First
name:
Last name:
E-mail :
UCD PERSONEL NUMBER :
No. of full time
students under
primary supervision at
present:
No. student supervised to
completion:
Permanent member of UCD academic
staff
Yes 
No 
If no, please indicate current status:
*Adjunct: Yes 
No 
Academic Contract: Yes  No 
Start date/ End Date contract:
_________________________________
*If Adjunct Staff; please contact the postgraduate office at medicine.research@ucd.ie for additional
form
Co-Supervisor: (if applicable)
Title:
First name:
Last name:
E-mail :
UCD PERSONEL NUMBER :
Other Supervisor: (if applicable)
Title:
First name:
Last name:
E-mail :
UCD PERSONEL NUMBER :
If more than one other supervisor is involved, please duplicate the above fields. Please note that other
supervisors are required only where their expertise is required for the student’s research on an ongoing
basis.
4
Nominator: (if different from principal supervisor)
Title:
First name:
Last name:
E-mail :
Address:
I am attaching a letter of
nomination
Yes 
No 
Doctoral Studies Panel: For guidelines on proposing suitable advisers, please contact
medicine.research@ucd.ie
Adviser 2:
Title:
First name:
Last name:
E-mail :
Details of funding for proposed study period:
Please state if these funds are guaranteed or if an application for funds has been made elsewhere
Source
Amount
Period
Is a substantial proportion of the student’s research to be carried out at an institution other than UCD or UCDaffiliated Sites?
YES 
NO 
If YES, prior approval of the College Graduate School must be sought – Please attach supporting
documentation
5
DECLARATION BY PRINCIPAL SUPERVISOR:
NOTE: Emails from the named individuals are acceptable in the place of signatures – please
attach copies.
I acknowledge that the particulars given by me in this application are in every respect true:
I have read and understood the academic regulations relating to this programme and are
aware of my responsibilities http://www.ucd.ie/registry/academicsecretariat/pol_regs.htm
Nominator
Signature
Date
Primary
Supervisor
Signature
Date
Co-Supervisor
Signature
Date
Additional
Supervisor
Signature
Date
6
REFEREE nominations for Student
Please enter the names, addresses and status of TWO referees who should be able to comment on your
academic suitability for research.
Referee
Status
Email Address
Referee
Status
Email Address
DECLARATION BY APPLICANT:
I acknowledge that the particulars given by me in this application are in every respect
true.
I have read and understood the academic regulations relating to this programme and are
aware of my responsibilities
http://www.ucd.ie/registry/academicsecretariat/pol_regs.htm
I also confirm that I meet the English Language entry requirements for UCD.
https://myucd.ucd.ie/admissions/english-language-requirement.ezc
Please attach certificates if applicable
NAME
SIGNATURE
DATE
7
SECTION 3: (To be filled out by the Postgraduate office)
DSP (Chair):
Title:
Last name:
First name:
E-mail :
PhD/MSc Meeting
GSB Meeting
Acceptance
SRI Rec.
DSP recommendation
Notification
8