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SCHOOL OF MEDICINE & MEDICAL

SCIENCE
PhD STUDENT APPLICATION FOR
REGISTRATION

SECTION 1 :( To be completed by the applicant)

Personal Details:
Titl Last name First name Country of Birth Country of
e Citizenship

Date of Birth Gender Mothers Maiden Name


(dd/mm/yyyy)

Permanent
Address:

Contact
Telephone
number:

Email Address:

Address for
correspondence
(If different, to
above -
please give dates)

First language:

Second language

1
UCD student
number
(If applicable)
Qualifications:

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:

2
September
2017

January
2018

May 2018

3
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.

4
SECTION 2 : (To be completed by the principal supervisor*)
*Please read the accompanying explanatory notes before completing this form

Principal Supervisor and Nominator:


Titl First Last name:
e: name:

E-mail :

UCD PERSONEL
NUMBER :
No. of full time No. student supervised to Permanent member of UCD
students under completion: academic staf
primary Yes No
supervision at If no, please indicate current
present: 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)


Titl First Last
e: name: name:

E-mail :

UCD PERSONEL NUMBER :

Other Supervisor: (if applicable)


Titl First Last
e: name: name:

E-mail :

UCD PERSONEL NUMBER :

5
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 students research on an ongoing basis.

Nominator: (if different from principal supervisor)


Title: First Last
name: name:

E-mail :
Addre I am attaching a letter
ss: of nomination
Yes No

Doctoral Studies Panel: For guidelines on proposing suitable advisers, please


contact
medicine.research@ucd.ie

Adviser 2:
Titl First Last
e: name: 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
Amoun
t
Period

Is a substantial proportion of the students research to be carried out at an


institution other than UCD or UCD-affiliated Sites?

YES NO

If YES, prior approval of the College Graduate School must be sought


Please attach supporting documentation

6
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

7
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

8
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

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