THE UNIVERSITY OF THE WEST INDIES
APPLICATION FOR
SPECIAL ADMISSION, OCCASIONAL, EXCHANGE AND STUDY ABROAD PROGRAMMES

The accompanying Instruction sheet provides detailed information on the completion of this application form.  All applicants are urged to read this information carefully.

SECTION A – PERSONAL DATA	
1.	Name	
Title	Last Name/Surname
	First Name	Middle Name(s)	
2.	a)	Former Name (if applicable)	
Title	Last Name/Surname	First Name
	Middle Name(s)	b)	Type of Former Name

	Maiden	(Prior to) Deed Poll	
3.	Have you previously applied to the UWI?

	Yes	No

4.	Have you previously been a student at the UWI?

	Yes	No	5.	If answer to question 4 is yes, please state the following:	
	a)	Identification Number

	b)	From (year)	c)	To (year)	d)	Campus	
	e)	Programme

6.	a)	Permanent Address:   Apt/Street/PO Box	7.	a)	Mailing Address (if different from 6):   Apt/Street/PO Box	

City/Town/Post Office/Post Office	Parish/County	City/Town/Post Office	Parish/County	
State	Zip/Postal Code	Country	State	Zip/Postal Code	Country	
b)	Name of Contact (if any)	b)	Name of Contact (if any)	c)	Active Dates (if applicable)
Fr ___/___/______	To ___/___/______	
8.	Home/Permanent Phone
	(	)	-	9.	Mailing Address Phone
	(	)	-	
10.	Cell Phone
	(	)	-	11.	Work Phone
	(	)	-	Ext:	
12.	Fax Number
	(	)	-	13.	Email Address			
14.	

Gender

	Female	Male	15.	Date of Birth  (dd/mm/yyyy)
	______/______/____________	16.	Tax Number/National ID	
17.	Marital Status

	Single	Married

	Common Law

	Legally Separated	Divorced	Widowed	18.	Religion/Denomination
	
19.	Country of Birth/National of

	20.	Country of Citizenship	21.	a)	Country of Residence	b)	Duration (yrs.)	
22.	a)	Do you have a disability? (This information is needed in case special facilities are required)

	Yes	No	b)	If yes, please specify

SECTION B – CAMPUS, FACULTY & COURSES	
23.	Period of Study

Academic Year

	Semester I

	Semester II

	Summer

Expected Admission date
________/________________
	mm	yyyy	24.	Level of Study

	Graduate

	Undergraduate
	25.	Campus

	Cave Hill

	Mona

	St. Augustine

	UWIDEC	26.	
Faculty

	Engineering

	Gender & Development Studies

	Humanities & Education

	Law

	Medical Sciences

	Pure & Applied Sciences

	Science & Agriculture

	Social Sciences	27.	Applicant Type

	Special Admission

	Occasional

	Exchange

	Study Abroad

28.	
a)	Please list the courses you wish to take at the UWI:	
Semester	Course Code	Course Title	[Official Use Only]	
			Signature of Department Head
		(where necessary)	Alternative Course	

					

					

					
					
b)	Please list alternative courses in the event that those listed above are not available in the semester which you indicated.	

					

29.	Proposed Area of Research (Graduate Level Applicants only)	

30.	

a)	Are you a UWI Staff Member?	Yes	No
If yes, state:

b)	Staff Identification Number:	_________________________________

c)	Campus:	_________________________________

d)	Department: 	_________________________________	31.	

a)	Are you a dependent of a UWI Staff Member?	Yes	No
If yes, state:

b)	Name of Staff Member:	_________________________________________

c)	Relationship to applicant:	_________________________________________

d)	Campus:	_________________________________________

e)	Department:	_________________________________________	
32.	a)	Do you wish to live in a Hall of Residence?
(see Instruction ____)

	Yes	No	b)	If yes, state Hall

	c)	If no, state preference for Hall attachment	
33.	How did you obtain information about the UWI?

	UWI Alumni	Direct Mail	Employer	Internet	Media

	School/College Fair	School Visit	Other : Please specify _______________________________	
	
SECTION C – ACADEMIC RECORD	
34.	Please list educational institutions attended and any other programmes or courses you have taken, beginning with the most recent.	
Institution Name & Address	From
(mm/yyyy)	To
(mm/yyyy)	Type of Programme (e.g. Cert/Dip/Deg)	Subject Area/Major	Class of Award/GPA	
Current Institution 	

___/________	Expected Completion Date

___/________				

Previous Institutions Attended	
	___/________	___/________				

	___/________	___/________				

35.	List all subjects passed at CXC (CSEC) General Proficiency, CXC (CAPE) and GCSE Ordinary and Advanced Levels	
CXC (CSEC) General Proficiency and GCSE Ordinary Level subjects passed	
Examining Body (e.g. CXC, Cambridge)	Level	Subject	Grade	Date Awarded (mm/yyyy)	

					

					

					

CXC (CAPE) Unit 1 & Unit 2 and GCSE Advanced Subsidiary & Advanced Level subjects passed	

					

	
36.	Please list any sporting/community/cultural or social activities in which you have been involved.

	
SECTION D – FINANCIAL RESOURCES	
37.	Expected Source of Funding

Government (specify):___________________________	Loan	Self	Institution of Origin

	Donor (specify):_______________________________	Parents	Award (specify):______________________________________________	
38.	Will you be able to meet your financial obligation by the time of acceptance?

	Yes	No 	
	
SECTION E - EMPLOYMENT INFORMATION	
39.	Please indicate current employment information (if applicable)	
a)	

Are you self employed?

	Yes	No	b)	If yes, Indicate the Type of Business	f)	Address:   Apt/Street/PO Box	
c)	Name of Employer (if applicable)		
d)	Position		
e)	From (dd/mm/yyyy)
	_____/______/____________	City/Town/Post Office	Parish/County	
	State	Zip/Postal Code	Country	
	
SECTION F – EMERGENCY CONTACT INFORMATION	
40.	Please indicate information for an emergency contact person	
a)	Name	
Title	Last Name/Surname	First Name	Middle Initial	b)	Relationship to Applicant	
c)	Permanent Address   Apt/Street/PO Box	d)	Emergency Contact Home/Permanent Phone
	(	)	-	
	e)	Emergency Contact Cell Phone
	(	)	-	
City/Town/Post Office	Parish/County	f)	Emergency Contact Work Phone
	(	)	-	Ext:	
State	Zip/Postal Code	Country		
	
SECTION G – REFEREE INFORMATION
41.	Name Two Referees (Exchange applicants only)	
a)	Name of Referee
	b)	Name of Referee	
Name of Organization
	Name of Organization	
Position
	Position	
Address:   Apt/Street/PO Box
	Address:   Apt/Street/PO Box	

		
City/Town/Post Office
	Parish/County	City/Town/Post Office	Parish/County	
State
	Zip/Postal Code	Country	State	Zip/Postal Code	Country	
Phone
(	)	-	Ext:	Phone
(	)	-	Ext:	
	
SECTION H - DECLARATION	
42.	I hereby certify that I have read and understood the instructions and the information necessary for completing this application and that all statements made are true and complete.  I understand that otherwise my admission to or registration in the University may be revoked.  I also understand that I am required to pay all fees before registration unless a current bilateral institutional arrangement makes this unnecessary.

__________________________________	______/______/___________
Signature of Applicant	Date (dd/mm/yyyy)	
	
FOR OFFICIAL USE ONLY	
Documents Received

	Application Fee	Receipt no.:__________________________

	Birth Certificate

	Marriage Certificate

	Deed Poll

	Transcripts

	CXC/GCE Certificates

	Referee Reports

	Other (specify):_______________________________________________	Original Documents Returned

__________________________________	______/______/____________
Signature of University Officer	Date 	(dd/mm/yyyy)	

	Approved		Not Approved

_________________________________________________	______/______/____________
Dean or Nominee/ Campus Coordinator	Date	(dd/mm/yyyy)	
Comments	

NC

NS

S

OFFICIAL ASSESSMENT:
Sponsored Contributing	Non Sponsored Contributing	Non-Contributing