Application for Admission Form
Content
2 & 3 Omirou Avenue, Eleftheria Square, P.O.Box 22425, 1521 Nicosia, Cyprus | Tel: +357 22661122, Fax: +357 22665458 | Email: [email protected] | www.ac.ac.cy
FOR OFFICE USE ONLY
APPLICATION FOR ADMISSION
Appl. No:
INSTRUCTIONS
1. Complete this form in block CAPITAL letters using a blue or a black pen.
2. Attach 1 recent passport size (4.5 X 3.5 cm) photo of yours in the space provided.
3. Sign the applicant's declaration on the last page of this form and submit the form along
with all necessary documents as per the Admission Procedure applicable to you according
to your nationality (described in the relevant leaflet or in our website) to:
PHOTO
Office of Admissions
American College
2 & 3 Omirou Avenue
P.O.Box 22425
1521 Nicosia
Cyprus
1. PERSONAL INFORMATION
Surname:
Given Names:
Date of Birth: (day/month/year)
Country of Birth:
Nationality:
Identity Card No:
Gender:
Marital Status:
Mother Language:
Religion: (optional)
Male ☐
Female ☐
Home Telephone:
Mobile:
Fax:
Single ☐
Married ☐
Mailing Address:
(include country and area code)
(include country and area code)
(include country and area code)
E-mail:
Postal Code:
Residence Country:
Country:
City:
Note: 1. Write your names as written on your passport. If your passport does not distinguish between “Surname” and “Given Names” (i.e. it only writes “Name of Bearer” or “Full Name”)
write the last name in order in the “Surname” box and the rest of the names in the “Given Names” box.
2. STUDY INFORMATION
Semester applying for:
Fall (October) ☐
Year applying for:
Spring (February) ☐
Summer (June)
☐
Higher Diploma
☐
Program of Study applying for:
Qualification applying for:
Master Degree
Study Type:
☐
Bachelor Degree
(tick only if applicable)
Distance Learning
☐
☐
Student Type: (tick only if applicable)
Erasmus Program Student
☐
Diploma
☐
Certificate
☐
English Language
☐
3. NON-CYPRIOT APPLICANT’S INFORMATION
Complete this section if you are a non-Cypriot applicant.
Passport No:
Country of Issue:
Date of Issue:
Expiry Date:
(day/month/year)
(day/month/year)
If you are already in Cyprus, answer the following question, tick the appropriate box and enclose a copy of your most recent Temporary
Residence Permit (TRP):
Date you entered Cyprus:
(day/month/year)
Category of Residence as per your most recent TRP:
Student
☐
Employment
☐
Visitor
☐
Other
☐
(specify)
If your most recent TRP is of “Student” category of residence write in section 5 about the educational institutions you have attended in Cyprus.
If your most recent TRP is of “Employment” category of residence write in section 8 about the employers you have worked for in Cyprus.
4. ERASMUS PROGRAM APPLICANT’S INFORMATION
Complete this section if you are a an Erasmus program applicant.
HOME INSTITUTION
Name:
Country:
CONTACT PERSON (E.G. ERASMUS / DEPARTMENTAL COORDINATOR)
Mailing Address:
Name:
Job Title:
Telephone:
Fax:
(include country and area code)
Postal Code:
(include country and area code)
E-mail:
City:
Country:
5. EDUCATIONAL BACKGROUND
List in chronological order (starting from the most recent one), the names of the educational institutions (e.g. Secondary School, College,
University) you have attended or are currently attending since and inclusive of your higher Secondary School.
Date of Attendance
From
Month Year
To
Month
Year
Name and Type of
Educational Institution
(e.g. Secondary School,
College, University)
Country
Average
Mark/
Grade
Qualification (and Area)
Awarded or to be
awarded (e.g. Diploma in
Hotel Management)
Language
of
instruction
6. ENGLISH LANGUAGE QUALIFICATIONS
List any English language qualifications you have ever obtained or aim to obtain by examination (e.g. IELTS, TOEFL, GCSE O level / IGCSE).
Examining Board or Body
Subject
Grade / Score
Month and Year
of Examination
7. OTHER EDUCATIONAL QUALIFICATIONS
List any educational qualifications (other than English language) you have ever obtained or aim to obtain by examination (e.g. LCCI, GCE A level and AS).
Examining Board or Body
Subject
Grade / Score
Month and Year
of Examination
8. PROFESSIONAL EXPERIENCE
List in chronological order (starting from the most recent one), all employment positions held during the last five years.
From
Month Year
To
Month
Year
Employer
9. HOBBIES
State your main hobbies (e.g. music, reading, swimming, football, cricket, travelling).
Country
Nature of work - Position
10. SPECIAL NEEDS
Tick one or more of the boxes below applicable to you. The information provided in this section will only be shared with appropriate College officials.
☐
No health problem or learning difficulty or disability
☐
Wheel-chair user
☐
Learning difficulty / Attention problem
☐
Have mobility difficulties
☐
Blind
☐
Need of personal care support
☐
Partially sighted
☐
Mental health difficulties
☐
Deaf
☐
Unseen disability
☐
Have a hearing impairment
☐
Disability/Special need not listed above
(e.g. dyslexia, apraxia, hyperactivity)
(e.g. diabetes, epilepsy, asthma)
(e.g. manual dexterity, back injury)
Notes: 1. Attach to this form a report confirming this learning difficulty / attention problem / disability.
2. Provide below further details regarding your learning difficulty / attention problem / disability (including details of use of any medications).
11. APPLICATION SOURCES AND REASONS
Indicate the source(s) and reason(s) that led you to apply to American College.
SOURCES
REASONS
☐
American College Representative
☐
School Counselor/Staff
☐
American College Current or Former Student
(specify)
☐
American College Staff
☐
Friend(s) or Relative(s)
☐
(specify)
☐
Reputation
☐
Available Programs of Study
☐
Reasonable Tuition Fees
☐
Possibilities of transfer to UK,
USA and other Universities
☐
College facilities
☐
Other
Advertisement
(specify)
(specify e.g. TV, radio, newspaper, magazine, billboard, promotional leaflets)
☐
Digital Advertisement
☐
Education Fair
☐
Other
(specify e.g. college website, banner in a website, social networking media, promotional email)
(specify)
12. APPLICANT’S DECLARATION
Applicant’s
Signature:
Date:
(day/month/year)
11-2015
I certify that the information given on this application is complete and accurate to the best of my knowledge.
I hereby apply for admission and if accepted and registered, I agree to comply with the regulations of American College.
I also declare that once accepted as a student of American College, I consent to the processing by the College of my personal data, in accordance
with the provisions of the Processing of Personal Data (Protection of Individuals) Law 2001.
I express explicit consent to American College to retain, process, disseminate and record all my personal data in any way the College deems
necessary. Additionally, I state my consent to and understanding that this information may be used by American College to communicate, either by
post, telephone, email or any other way, with me regarding any services, offers and notifications at a later date. In the event that I do not wish to be
contacted further, I will inform American College appropriately.
FOR OFFICE USE ONLY
APPLICATION FOR ADMISSION
Appl. No:
INSTRUCTIONS
1. Complete this form in block CAPITAL letters using a blue or a black pen.
2. Attach 1 recent passport size (4.5 X 3.5 cm) photo of yours in the space provided.
3. Sign the applicant's declaration on the last page of this form and submit the form along
with all necessary documents as per the Admission Procedure applicable to you according
to your nationality (described in the relevant leaflet or in our website) to:
PHOTO
Office of Admissions
American College
2 & 3 Omirou Avenue
P.O.Box 22425
1521 Nicosia
Cyprus
1. PERSONAL INFORMATION
Surname:
Given Names:
Date of Birth: (day/month/year)
Country of Birth:
Nationality:
Identity Card No:
Gender:
Marital Status:
Mother Language:
Religion: (optional)
Male ☐
Female ☐
Home Telephone:
Mobile:
Fax:
Single ☐
Married ☐
Mailing Address:
(include country and area code)
(include country and area code)
(include country and area code)
E-mail:
Postal Code:
Residence Country:
Country:
City:
Note: 1. Write your names as written on your passport. If your passport does not distinguish between “Surname” and “Given Names” (i.e. it only writes “Name of Bearer” or “Full Name”)
write the last name in order in the “Surname” box and the rest of the names in the “Given Names” box.
2. STUDY INFORMATION
Semester applying for:
Fall (October) ☐
Year applying for:
Spring (February) ☐
Summer (June)
☐
Higher Diploma
☐
Program of Study applying for:
Qualification applying for:
Master Degree
Study Type:
☐
Bachelor Degree
(tick only if applicable)
Distance Learning
☐
☐
Student Type: (tick only if applicable)
Erasmus Program Student
☐
Diploma
☐
Certificate
☐
English Language
☐
3. NON-CYPRIOT APPLICANT’S INFORMATION
Complete this section if you are a non-Cypriot applicant.
Passport No:
Country of Issue:
Date of Issue:
Expiry Date:
(day/month/year)
(day/month/year)
If you are already in Cyprus, answer the following question, tick the appropriate box and enclose a copy of your most recent Temporary
Residence Permit (TRP):
Date you entered Cyprus:
(day/month/year)
Category of Residence as per your most recent TRP:
Student
☐
Employment
☐
Visitor
☐
Other
☐
(specify)
If your most recent TRP is of “Student” category of residence write in section 5 about the educational institutions you have attended in Cyprus.
If your most recent TRP is of “Employment” category of residence write in section 8 about the employers you have worked for in Cyprus.
4. ERASMUS PROGRAM APPLICANT’S INFORMATION
Complete this section if you are a an Erasmus program applicant.
HOME INSTITUTION
Name:
Country:
CONTACT PERSON (E.G. ERASMUS / DEPARTMENTAL COORDINATOR)
Mailing Address:
Name:
Job Title:
Telephone:
Fax:
(include country and area code)
Postal Code:
(include country and area code)
E-mail:
City:
Country:
5. EDUCATIONAL BACKGROUND
List in chronological order (starting from the most recent one), the names of the educational institutions (e.g. Secondary School, College,
University) you have attended or are currently attending since and inclusive of your higher Secondary School.
Date of Attendance
From
Month Year
To
Month
Year
Name and Type of
Educational Institution
(e.g. Secondary School,
College, University)
Country
Average
Mark/
Grade
Qualification (and Area)
Awarded or to be
awarded (e.g. Diploma in
Hotel Management)
Language
of
instruction
6. ENGLISH LANGUAGE QUALIFICATIONS
List any English language qualifications you have ever obtained or aim to obtain by examination (e.g. IELTS, TOEFL, GCSE O level / IGCSE).
Examining Board or Body
Subject
Grade / Score
Month and Year
of Examination
7. OTHER EDUCATIONAL QUALIFICATIONS
List any educational qualifications (other than English language) you have ever obtained or aim to obtain by examination (e.g. LCCI, GCE A level and AS).
Examining Board or Body
Subject
Grade / Score
Month and Year
of Examination
8. PROFESSIONAL EXPERIENCE
List in chronological order (starting from the most recent one), all employment positions held during the last five years.
From
Month Year
To
Month
Year
Employer
9. HOBBIES
State your main hobbies (e.g. music, reading, swimming, football, cricket, travelling).
Country
Nature of work - Position
10. SPECIAL NEEDS
Tick one or more of the boxes below applicable to you. The information provided in this section will only be shared with appropriate College officials.
☐
No health problem or learning difficulty or disability
☐
Wheel-chair user
☐
Learning difficulty / Attention problem
☐
Have mobility difficulties
☐
Blind
☐
Need of personal care support
☐
Partially sighted
☐
Mental health difficulties
☐
Deaf
☐
Unseen disability
☐
Have a hearing impairment
☐
Disability/Special need not listed above
(e.g. dyslexia, apraxia, hyperactivity)
(e.g. diabetes, epilepsy, asthma)
(e.g. manual dexterity, back injury)
Notes: 1. Attach to this form a report confirming this learning difficulty / attention problem / disability.
2. Provide below further details regarding your learning difficulty / attention problem / disability (including details of use of any medications).
11. APPLICATION SOURCES AND REASONS
Indicate the source(s) and reason(s) that led you to apply to American College.
SOURCES
REASONS
☐
American College Representative
☐
School Counselor/Staff
☐
American College Current or Former Student
(specify)
☐
American College Staff
☐
Friend(s) or Relative(s)
☐
(specify)
☐
Reputation
☐
Available Programs of Study
☐
Reasonable Tuition Fees
☐
Possibilities of transfer to UK,
USA and other Universities
☐
College facilities
☐
Other
Advertisement
(specify)
(specify e.g. TV, radio, newspaper, magazine, billboard, promotional leaflets)
☐
Digital Advertisement
☐
Education Fair
☐
Other
(specify e.g. college website, banner in a website, social networking media, promotional email)
(specify)
12. APPLICANT’S DECLARATION
Applicant’s
Signature:
Date:
(day/month/year)
11-2015
I certify that the information given on this application is complete and accurate to the best of my knowledge.
I hereby apply for admission and if accepted and registered, I agree to comply with the regulations of American College.
I also declare that once accepted as a student of American College, I consent to the processing by the College of my personal data, in accordance
with the provisions of the Processing of Personal Data (Protection of Individuals) Law 2001.
I express explicit consent to American College to retain, process, disseminate and record all my personal data in any way the College deems
necessary. Additionally, I state my consent to and understanding that this information may be used by American College to communicate, either by
post, telephone, email or any other way, with me regarding any services, offers and notifications at a later date. In the event that I do not wish to be
contacted further, I will inform American College appropriately.
