UAS - Example Application Form



School of Mathematics, Statistics and Applied Mathematics

MA435 – Undergraduate Ambassador Module

Application Form

Please fill out this form and return it to Dr Rachel Quinlan in the School of Mathematics, Statistics and Applied Mathematics by Monday September 9 if you may be interested in taking the Undergraduate Ambassador Module (MA435) in the academic year 2013-14. You may return the form either by email to rachel.quinlan@nuigalway.ie or on paper to the Office of the School of Mathematics, Statistics and Applied Mathematics (ADB-G025 on the ground floor of Áras de Brún). By entering this application process you are not committing yourself to accepting a place on the module if one is offered. All information on this form will be handled confidentially.

SECTION 1 : Personal Details

Name : NUI Galway student number:

e-mail address : Phone number:

Programme and Year (e.g. 3rd Mathematical Studies) :

SECTION 2 : Courses taken at NUI Galway

In the tables below please list the courses that you have taken to date at NUI Galway, and the grades A,B,C or D obtained as follows : A: 85-100 B:70-84 C:55-69 D:40-54

1. 1st Year

|Subject Name (state hons or pass) |Course Code (if known) |Grade |

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2. 2nd Year (list mathematical and related courses only)

|Module Name |Module Code |Grade |

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3. 3rd Year if applicable (list mathematical and related courses only)

|Module Name |Module Code |Grade |

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SECTION 3 : Information in support of your application

Please give details of any relevant experience (including any voluntary work), skills, special interests and other information that would support your application (max 200 words).

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3 Please give clear reasons why you want to take this course and work in a school (continue on a separate sheet if necessary).

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SECTION 4 : Additional Information

Do you have any past convictions that may be relevant to this application to take a module that involves working with school children? Yes / No

Do you agree to the University seeking clearance for you to work on this module from the Garda Vetting Office? Yes / No

Signature __________________________________ Date __________________

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