Undergrad Application Form A

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FORM A
COLLEGE OF SCIENCE, ENGINEERING & FOOD SCIENCE, UCC
CHANGE REQUEST
UNDERGRADUATE
FORM FOR SUBMISSION TO
*SCHOOL OF
TO BE COMPLETED BY STUDENT
Applicants are asked to note the deadlines for the submission of applications on SEFS/*Schools websites.
Surname (Block letters please) __________________________Other Name(s) _________________________________
Date of Birth (DD/MM/YY) ______________Telephone No.__________________ Student No.___________________
Address for Correspondence _________________________________________________________________________
________________________________________________________________________________________________
State course and year for which currently registered/most recently registered and academic year (e.g. 2014/15):
________________________________________________________________________________________________
Change Requested and Reason:_______________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Signature: ___________________________________
Date: ________________________
FOR OFFICE USE ONLY (*SCHOOL RECOMMENDATION)
Approved
Justification: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Implication(s) if any: _____________________________________________________________
_____________________________________________________________________________
Refused
Justification: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Signature:_________________________________
Date: __________________
Head of Department/*School/Nominee
Completed applications must be returned to your Departmental/School Administrator.
* In this document the term “school” refers to the established schools within the College with the inclusion of the Departments of Physics and Chemistry.
T.Dwan SEFS (July 2015)

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