Liverpool School of Tropical Medicine

APPLICATION FORM
Personal Details:
Title – Dr/Mrs/Mr/Miss/Other: Surname/Family Name:

First Name: Middle Name:

Previous Last Name (if applicable): Male/Female:

Country of Birth: Date of Birth:

Nationality: Passport Number:

Country of Issue:
Expiry Date:
Have you continued to live in your country of birth up to the present day, with no gaps in
residence? Yes/No
What country have you been living in for the past three years?

Do you need to apply for a visa to come to the UK? Yes/No

Permanent Address: Address for Correspondence (if different)

Telephone No. Telephone No.

Mobile No: Email address:

Programme Application Details:

Programme Title:
Proposed Start Date:
If the programme includes a choice of modules / options, please indicate your
preference(s) here:

Academic Qualifications: (please attach copies of certificates)

University/Institution Attended:

Degree Title (Subject):

Qualification Gained (BSc / Certificate / Diploma):

Dates of Attendance DD/MM/YYYY From: To:

Date of Award DD/MM/YYYY:

Professional Qualifications: (please attach copies of certificates)
Please give details of any additional professional or other qualifications

Employment History: (if applicable)

Position Held Dates Employer & Brief Description of Responsibilities
Country

(Please continue on a separate sheet if necessary)

English Language Qualifications: (for applicants whose first language is not English)
We require a minimum score of 6.5 for the IELTS examination OR 88 for the
TOEFL iBT examination OR 570 for the TOEFL paper-based examination.
IELTS Score Date Taken

TOEFL Score Date Taken

Other Score/Grade Date Taken

Computer Skills:

Other Relevant Skills and Experience:

Future plans (what do you intend to do after completing this programme?):

Health: Details of any health issues, disabilities or support needs

Criminal Convictions:

Do you have any criminal convictions?

(If you do not answer this question we cannot process your application)

Yes No

If you have answered yes, please give details of the conviction in terms of sentence
served or caution received.

*Referees: (separate form attached)

NB. Applicants are requested to ask their referees to e-mail, post or fax references directly
to the Programme Administrator as soon as possible. References by e-mail should be
followed by a signed copy by post / fax.
Name Name

Position Position

Address Address

Email Email

Telephone No. Telephone No.

* Note concerning referees: Referees should be Senior Academic and/or Professional persons who
are currently responsible, or have recently been responsible, for supervising you. Close personal
friends and family are not acceptable as referees.

DTM&H, MTropID, MTropPaeds, DICHC - Both referees must be medically qualified persons who hold
official appointments.

MIPH - The first referee should be someone in a position to comment officially on your recent work
experience in the field of community health. The second referee should be able to comment officially on
your previous academic performance. Please note that work colleagues, friends or fellow students are not
acceptable as official referees.

DHA / MHS / MHHPM - Referees should be Senior Academic and/or Professional persons who are currently
responsible, or have recently been responsible, for supervising you.

Other MSc - At least one referee should be a member the academic staff of the institution at which you last
studied.
Personal Statement: (Please give details of why you applied for the programme and
what you expect to gain from attending the programme)

Financial Support/Sponsorship
• Candidates must provide evidence that they will have sufficient funds available for
their fees and maintenance during the programme. If self-funded, please enclose a
recent bank statement.

• If sponsored please state the name of authority responsible for payment of tuition
fees and enclose written confirmation from sponsors.

• Please note that family member sponsorship is classified as self-funding, and the
requirements for self-funded students apply.

1. Self-funded: Yes / No. If YES, please enclose a recent Bank Statement.

2. Sponsored: Yes / No. If YES, please complete the questions below:

Have you applied for a scholarship / sponsorship: Yes / No

If ‘yes’, please state name and address of funding body:

Have you received a scholarship / sponsorship offer: Yes / No

If ‘Yes’, please enclose a copy of your offer letter.
If ‘No’, please state the date by which you expect to have received an offer:
Please ensure that you notify the Programme Administrator and forward a copy of your
offer letter as soon as it becomes available.
Please indicate where you first heard about the programme: Please tick one box ()

 University Prospectus

Supervisor

Education Exhibition/Careers Fair Venue …………………………………..................

WWW Please specify ………………………………………

Professional Journal Please specify ………………………………………

Alumni Newsletter

Previous LSTM Student

Friends/Relatives

Direct Mailing

Other Please specify ………………………………………

Application forms may be e-mailed or faxed to the appropriate programme administrator:

Fax: 0044 151 705 3347

Laura Hand: l.c.hand@liverpool.ac.uk Telephone: 0044 151 705 3208

MSc in Tropical and Infectious Diseases
MSc in Tropical Paediatrics
MSc in International Public Health
MSc in International Public Health (Humanitarian Assistance)
MSc in International Public Health (Planning & Management)

Eleanor Carr: e.carr@liverpool.ac.uk Telephone: 0044 151 705 3359

Diploma in Tropical Medicine and Hygiene
Diploma in Humanitarian Assistance
MSc in Humanitarian Studies
MSc in Humanitarian Programme Management

Katie Douglas: c.e.douglas@liverpool.ac.uk Telephone: 0044 151 705 3321

Diploma in International Community Health Care
MSc in Biology and Control of Parasites and Disease Vectors
MSc in Molecular Biology of Parasites and Disease Vectors
MSc in International Public Health (Sexual and Reproductive Health)

Alternatively, applications can be posted to:

(Programme Administrator)
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool
L3 5QA, UK
Check-list

Evidence of academic or professional qualifications

(including transcripts where necessary)

Copies of English language certificates (where appropriate)

IELTS / TOEFL / WAEC

Evidence of funding.

Family member sponsorship is classified as self funding. If a family member is

responsible for your fees and living expenses, a bank statement or letter from the bank
is required along with a supporting letter.

I have forwarded the reference forms to two referees

Previous Last Name: If you have mentioned a change in name, please provide
supporting evidence to support this e.g. marriage certificate.

Other relevant items (please specify)

Completed Equal Opportunities Monitoring Form

By submitting this application I agree to LSTM and its associates processing personal data contained in this form, or other
data which LSTM may obtain from me or other sources. I agree to the processing of such data for any purpose
connected with my studies or my health, welfare and safety, or for any other legitimate reason. I understand that my
personal data will not be disclosed to third parties without my permission.
Equal Opportunities Monitoring
In order for us to monitor equal opportunities, we would appreciate it if you would answer the following
questions.

1. Ethnic Origin

White British 10 Chinese 34

White Irish 10 Other Asian Background 39
White Scottish 10
Irish Traveller 14
Other white background 10 Mixed – White and Black Caribbean 41
Mixed – White and Black African 42
Black or Black British – Caribbean 21 Mixed – White and Asian 43
Black or Black British – African 22 Other Mixed background 49
Other Black Background 29 Other Ethnic Background 80

Asian or Asian British – Indian 31 Not Known 90

Asian or Asian British – Pakistani 32
Asian or Asian British – Bangladeshi 33 Information Refused 98

…………………………………………………………………………………………………………..................................................

2. Disability .

In the application form we have asked about any disability/ special needs in order that we can provide
students with the best support.

For planning purposes we would appreciate it if you could identify the most appropriate description to
describe your disability, and enter the corresponding number in the above box.

Disabilities / Support Required

0 You do not have a disability or are not aware of any additional support requirements in study or
accommodation

1 You have a specific learning difficulty (e.g. Dyslexia)

2 You are blind / partially sighted

3 You are deaf / hard of hearing

4 You are a wheelchair user / have mobility difficulties

5 You have mental health difficulties

6 You have an unseen disability, e.g. diabetes, epilepsy, or a heart condition

7 You have two or more of the above disabilities/difficulties

8 You have a disability, special need or medical condition not listed above

If you would like to discuss support, access and facilities for disabled people, please contact The Welfare
and Accommodation Officer.

Rebecca Riley
0151 705 3176
rriley@liv.ac.uk