denysholland_app_2013-14.doc

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UCL DENYS HOLLAND SCHOLARSHIP APPLICATIONFORM

Please read the accompanying General Notes & Guidance Notes beforecompleting this application form.

Please complete ALL sections even if only entering not applicable (n/a).

SECTION A

1) PERSONAL DETAILSSurname/Family Name

First Name/s

Title - select -

UCAS Application Number

Nationality

Date of Birth dd/mm/yyyy Age next Sept23rd years

2) CONTACT DETAILS (If successful, we will contact you by email):

Email Address

Mobile/Cell Phone

3) CORRESPONDENCE ADDRESS (Please inform us via email if this addresschanges):

Street Address

City

County/Province

Country of Domicile

Postcode

Telephone incl. area code

4) UCL STUDY FOR WHICH FUNDING IS INTENDEDQualification Sought BA, BSc, BEng, MEng, MSci etc.

Programme/Course Title

UCL Department/Institute

Method of Study - select -

Admissions/Enrolment Status - select -

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Programme Start Date:Expected or Actual registration/enrolment mm/yy

Fee Status (specified in the offerletter)

- select -

SECTION B

5) FINANCIAL CIRCUMSTANCES & BACKGROUND

The Denys Holland Scholarship is intended for students in financial need, those who wouldbe unable to study at UCL without financial assistance.

5.1Please list past / current Prizes, Awards and ScholarshipsWe may request proof (copies of award letters or certificates) for the information youprovide below:

Name of Prize, Award orScholarship

Please list only those awarded on thebasis

of academic merit/achievement

PurposeWhat was the prize, award or

Scholarship awarded for?

OverallValue GB £

Dateawarded

(MM/YY)

£

£

£

£

£

5.2In the 12 months immediately preceding the start of your programme at UCL,have you been / are you currently / will you be:

Please tick all that apply and provide details:(√) Employer name and location

city, country

StartDate (MM/YY)

EndDate

(MM/YY)

Position held

WorkingFull Time

WorkingPart-Time

StudyFull Time

Study

Part-Time

Other e.g.

voluntary /Gap

5.3What is your expected net income during the 12 monthsimmediately preceding the start of your UCL programme which youwill be able to save as a contribution to your studies?

£

Please provide evidence of income from employment

5.4

Do you intend to work whilst studying?

Term-Time No Yes, Full-Time Yes, Part-Time

Vacation/Summer

No Yes, Full-Time Yes, Part-Time

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UCL recommends that full-time students work no more than 15 hours a week during term time.

5.5If you expect to receive contributions from anyoneduring the course of your programme at UCL, pleaseprovide details. You should include members of yourhousehold or anyone else including an employer (otherthan pay which you earn):

£

Name:Relationship to you:

5.6Please give full details of your current financial circumstances, an outline of thefunding you have already secured and how this scholarship would contribute toyour financial plan for studying at UCL.

You must include a word count at the top of this statement – Max 500 words:

6) OTHER FINANCIAL SUPPORT

This funding may not be sufficient to cover the full cost of your study, including tuition feesand living costs.Please use the table below to explain how you plan to cover the costs of your studies atUCL:

6.1Funding already secured for study at UCL from September

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Continue on separate sheet if necessary and title this 5.6



SCHOLARSHIP / GRANT NAME

VALUEPER

YEAR(GBP£)

DURATION

(Years)

PURPOSE(Fees, living costs, equipment, travel,

etc.)

£

£

£

£

6.2Please note: UCL expects you to make all reasonable efforts to secure reasonable fundingto enable your study.In particular, all students are expected to apply for funding in their country of domicile,where appropriate.

Please list all known sources of financial support, including Scholarships, Grants,Bursaries and Loans, for which you are eligible and which you intend to apply forto fund your undergraduate studies at UCL:

SOURCE OF

FINANCIALSUPPORT

AMOUNT APPLIED

FOR£

AMOUNT

SECURED, ORDATE RESULT

EXPECTEDMM/YY

CONTACT DETAILS

OF AWARDING /LENDING BODY

1 £

2 £

3 £

4 £

5 £

6 £

7 £

• Results of the outcome of any successful applications may be requested at our

discretion.

• In the event of successful applications, copies of award letters must be submitted to

the Student Funding Office.

7) TOTAL FUNDING AVAILABLE TO YOU

7.1Please summarise the total funding you have already secured or plan to securefor your programme of study at UCL from the following sources:

2013-2014£ 2014-2015£ 2015-2016£i) Yourself (e.g. personal savings)

£ £ £

ii) Yourself (e.g. term-

time / vacation part-timeemployment)

£ £ £

iii) FinancialAssistance(as in 6.1 + 6.2)

£ £ £

iv) Funding – fromhouseholdmembers

£ £ £

v) Funding fromother sources (e.g.

Maintenance Grant)

£ £ £

SUBTOTAL A £ £ £

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Loans frommembers of yourhousehold

£ £ £

Loans from othersources(e.g. Tuition andMaintenance Loan)

£ £ £

SUBTOTAL B £ £ £

TOTAL AMOUNTAVAILABLE (A+B)

£ £ £

7.2What is the minimum amount of financial support that you would need from UCLin each year to enable you to take up your place?

2013-2014£

2014-2015£

2015-2016£

£ £ £

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SECTION C

8) PERSONAL STATEMENTProfessor Denys Holland, in whose memory this scholarship was created, took a keeninterest in students’ extra-curricular activities as well as in their academic progress. Oneof his principal concerns was that students entered fully into college life. Please describeyour academic interests and explain your educational and career ambitions. Alsocomment on your general interests, and state how you would make use of the activitiesoffered by UCL and the Student Union.

You must include a word count at the top of the statement - 500 words max

CONFIDENTIALITY - DATA PROTECTION ACT (1998)

University College London is a data controller in terms of the 1998 legislation. TheStudent Funding Office (SFO) follows UCL policy in matters of data protection. The datarequested in this form is covered by the notification provided by UCL under the DataProtection Act. Personal data will be used to administer your award as appropriate, and

for statistical purposes and electronic records keeping.

The data will not be passed to any other third party without your consent, except whenUCL is required to do so by law. Any formal enquiries concerning the use of data notedhere should be addressed to the UCL Data Protection Officer.

Continue on separate sheet if necessary and title this (8)

Once you are happy with your application, please print the form and date and signbelow or you may type your name and email us this application..

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9) APPLICANT’S DECLARATION

Your application will not be valid unless this section is signed and dated:

By submitting this application to UCL on:

(Submission date)

I,

(Name)

Declare that:

• I understand that my application is valid only if all required information is provided andall required additional documents enclosed;

• the information I have provided is accurate and true to the best of my knowledge;

• If required, I authorise UCL to provide a copy of my application to the funders of thescheme in the event that my application should be successful.

• I agree to inform the Student Funding Office immediately of any other scholarships,grants or awards I am offered or awarded (by an external funder, other offices within UCLor my admitting department) subsequent to submitting this application, and to providedetails and proof of their purpose, value, and duration, if requested. I understand that additional funding awarded from another source may be taken into account in thecalculation of any scholarship I may receive.

• I authorise UCL to provide a copy of this scholarship application as well as a copy of my

UCAS application to the Trustees of the Denys-Holland Trust, from which the scholarshipis funded.

• I understand that documents submitted with this application will not be returned to me.

Signature

FOR OFFICE USE ONLY - ADMINISTRATIVE CHECKLIST

Checklist:√

Sections 1 – 12 completed

Applicant’s Declaration completed

Evidence of income or Date Expected:

Post to:Student Funding Office, South Wing G19University College London,Gower Street,LondonWC1E 6BT, United Kingdom

Or, email to:[email protected]

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mailto:[email protected]

mailto:[email protected]

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