Application Form - Bahrain - Institute of Leadership

Royal College of Surgeons in Ireland
Academic Programme Application Form
BAHRAIN
***Completing Your Application Form***
Please complete in BLOCK CAPITAL LETTERS using a BLACK pen.
Complete all sections, adding extra labelled sheets if necessary.
Attach 1 x photo here
PERSONAL DETAILS:
Title (Mr/Dr/Ms/etc.) :
Family Name (Surname):
First Name:
Date of Birth:
(Required for Higher Education Authority - Ireland)
Previous RCSI Student No. (if applicable) :
Address for ALL Correspondence
Address
Tel:
Mobile:
Email:
Nationality:
For office use only
Program: Ack: Com:
OS: OL: ACC:
QUE:
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SOURCE OF FUNDING: (Please Tick)
Self
Employer:
Other Funding (please state):
PROGRAMME YOU WISH TO UNDERTAKE (please ensure you tick clearly):
MSc/Post Graduate Programmes:
MSc/Postgrad Dip. in Healthcare Management
MSc/Postgrad Dip. in Quality & Safety in Healthcare Management
Diploma in Leadership & Organisational Development
WHERE DID YOU HEAR ABOUT OUR PROGRAMMES (Please Tick)
Website:
Employer:
Exhibition:
Current/past student:
Newspaper/Magazine (specify):
Other (specify):
EMPLOYMENT HISTORY:
The following section must be completed - do not substitute with a CV
Employer Name & Address (present first) :
Job Title:
From
Dates:
To
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HIGHER EDUCATION and/or PROFESSIONAL QUALIFICATIONS (in date order, most recent first)
University
Completed Qualification Subject
Language of
instruction
Result
GPA*
ENGLISH LANGUAGE QUALIFICATIONS: (only for applications to RCSI-Bahrain & RCSI-Dubai )
IELTS:
Listening: Reading: Writing:
Speaking:
TOEFL:
Overall
Band:
Total Score:
Test if Written English/Essay Score:
OTHER COURSES & EXPERIENCE: (relevant to your application)
Date of Course Title of Course Qualification (including grade)
PLEASE NOTE: All information is kept confidential and used only for the purpose for which it was collected. Only
completed application forms will be reviewed. CVs may be attached as additional information but not as a substitute
for the application form.
CHECKLIST FOR YOUR APPLICATION:
1.Completed Application Form (additional information & CV may also be attached)
2. Official Degree/Professional Qualification Transcripts (original or notarised copy)
3. Passport-size Photo (attached to page 1)
4. English Certificate of Competency (where English is not your first language)
* GPA Grade Point Average (Check with university where you completed your degree for this calculation)
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APPLICATION SUBMISSION DETAILS:
Please note, you may be additionally requested to submit references
Institute of Leadership & Healthcare Management,
Royal College of Surgeons in Ireland - Bahrain,
PO Box 15503,
Busaiteen,
KINGDOM OF BAHRAIN
Tel:
Fax:
Website:
+ 973 17 351 450 Ext 2490
+ 973 17 583 600
www.rcsileadership.org
Please read the following before signing your Application Form:
I certify that the information on this application form is complete and accurate.
Signature:
Date:
Please tick this box if you DO NOT wish to receive marketing information from the RCSI
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