TIER 4 (G)

A. Payment Details
TIeR 4 (GeneRAl) APPlICATIOn FORM
There is a separate help text leaflet available with this form. Where a question in this form has information
available in the help text leaflet it will be marked with (ht)
Please complete this form in block capitals and black ink
A1. Is your sponsor a Highly Trusted Sponsor?
A2. Tick the applicable fee (ht):
YeS nO
The student is making a Tier 4 (General) student application by post - £394
The student is making a Tier 4 (General) student application at a Public Enquiry Office
A3. Address for correspondence in the UK (ht)
House number/name
Address line 1
- £716
Address line 2
Address line 3
Town/City
County/District
Postcode
A4. If you are using a solicitor or other authorised immigration advisor to help you with this
application form, you should enter the name of that person here (ht)
A5. Your full Name (ht):
A6. Your date of birth: (ht)
D D M M Y Y Y Y
A7. Please select the method of payment from the list below (ht)
United Kingdom postal order (payable to
‘Home Office’) - go to question A20
Cheque/bankers draft (payable to
‘Home Office’) - go to question A8
Visa/Mastercard/Amex - go to question A11 Delta / Maestro - go to question A11
A8. Account number A9. Sort code A10. Cheque number - go to question A20
A11. Name on card (ht)
A12. Card number (the long number across the centre of the card):
A13. Valid from: A14. Valid to: A15. Issue number A16. CVV security number
/ / (where
available)
A17. Amount - please tick appropriate box (ht) - £394 - £716
A18. Cardholder’s signature: A19. Date
D D M M Y Y Y Y
Tier 4 (G) Application Form (version 10/12) - page 3
(3 digit number or
4 digit number for
Amex)
A20. Please provide details of any dependant applications that are being submitted with this form.
Please photocopy this page if more space is needed.
IMPORTANT – each dependant must also complete their own Tier 4 Dependant form (ht).