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APPLICATION FORM
Personal Details:
Title – Dr/Mrs/Mr/Miss/Other: Surname/Family Name:
English Language Qualifications: (for applicants whose first language is not English)
We require a minimum score of 6.5 for the IELTS examination OR 88 for the
TOEFL iBT examination OR 570 for the TOEFL paper-based examination.
IELTS Score Date Taken
Computer Skills:
Criminal Convictions:
Yes No
If you have answered yes, please give details of the conviction in terms of sentence
served or caution received.
Position Position
Address Address
Email Email
DTM&H, MTropID, MTropPaeds, DICHC - Both referees must be medically qualified persons who hold
official appointments.
MIPH - The first referee should be someone in a position to comment officially on your recent work
experience in the field of community health. The second referee should be able to comment officially on
your previous academic performance. Please note that work colleagues, friends or fellow students are not
acceptable as official referees.
DHA / MHS / MHHPM - Referees should be Senior Academic and/or Professional persons who are currently
responsible, or have recently been responsible, for supervising you.
Other MSc - At least one referee should be a member the academic staff of the institution at which you last
studied.
Personal Statement: (Please give details of why you applied for the programme and
what you expect to gain from attending the programme)
Financial Support/Sponsorship
• Candidates must provide evidence that they will have sufficient funds available for
their fees and maintenance during the programme. If self-funded, please enclose a
recent bank statement.
• If sponsored please state the name of authority responsible for payment of tuition
fees and enclose written confirmation from sponsors.
• Please note that family member sponsorship is classified as self-funding, and the
requirements for self-funded students apply.
University Prospectus
Supervisor
Alumni Newsletter
Friends/Relatives
Direct Mailing
(Programme Administrator)
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool
L3 5QA, UK
Check-list
Evidence of funding.
Previous Last Name: If you have mentioned a change in name, please provide
supporting evidence to support this e.g. marriage certificate.
By submitting this application I agree to LSTM and its associates processing personal data contained in this form, or other
data which LSTM may obtain from me or other sources. I agree to the processing of such data for any purpose
connected with my studies or my health, welfare and safety, or for any other legitimate reason. I understand that my
personal data will not be disclosed to third parties without my permission.
Equal Opportunities Monitoring
In order for us to monitor equal opportunities, we would appreciate it if you would answer the following
questions.
1. Ethnic Origin
…………………………………………………………………………………………………………..................................................
2. Disability .
In the application form we have asked about any disability/ special needs in order that we can provide
students with the best support.
For planning purposes we would appreciate it if you could identify the most appropriate description to
describe your disability, and enter the corresponding number in the above box.
0 You do not have a disability or are not aware of any additional support requirements in study or
accommodation
8 You have a disability, special need or medical condition not listed above
If you would like to discuss support, access and facilities for disabled people, please contact The Welfare
and Accommodation Officer.
Rebecca Riley
0151 705 3176
rriley@liv.ac.uk