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BOOKING FORAT
APPL|CATTON FOR ADM|SS|ON - wARsAsH MATRiIME ACADE^ y

Please complete the Booking Form in full (using BLOCK capltals througnout), and retu.n it with the depostt payment and [Link] otyour supporting

Personal lnformation
ADRE gu trtYAN Al l.s(
Cr OOg , NNRL\AbA NppT Date of Birth
2-G ocroBER tqq3
.sAqAq sAH SIVAN SANKUL , NEAR.
fIV'{AL\ B\zAR I \<Nv ILTRL-! ,cHrpLud Mobite Tet. No-
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qt5 6o5 , RATNAqtet /[Link] suCi qn. r qdre mail - com
Post Code (UK onty) Discharge Book No. r.,tuM 2c, 6l2 tl
Do you have any ll 'Y6', plere pm:de 6 frln supfoding
dhabitities (i.e.
Dystexia)
,*@ documnt tbn to eiable us b 6u€ FU have
er}thing ).r .@d b 6deb FU .cr:e. L LL\L33+
Do you have any Criminal Convictionsl
t;re. Ptace of Birth
PLEASE REFER TO NOTE 1

Country of Perrnanent Residence

aNo15 tCountry) Ct{r PLU N /M\uARhgLlrRA, IND lA
Ptease Circte Residential Category
Nationatity
f-N D]. AN PLEASE REFER TO NOT€ 2 1734 56 It'\_

Do you need a Tier 4 Student Visa ts study in the UK Do you currenlty live il] the IJK? ,".@
Have you ever been issued wiLb a visa to study jn the UK even ifyou did not use i!? *'@
Have you ever had a visa to enter the UX {NOT FOR STUDY}, ercn iJ yoo did not llse it?
"*@
Have you ever been issued wirh a Confirmation of Acceptance for Studies (CASI for a Tier 4 visai *'@
Have you ever studied in the UX before you applied to Warsash t aritime Academy? (southampton Sotenr Unit€rsjty) ,*@
Have you ever had a UK visa application refused? *'@
Will you be applying for your lier 4 visa from a country wtjch is different from your passport, if so which country?
NO
lfyou have answered Yes lo any of the above questjons then ptease send the retevant documents when returning your apptication form to
[Link]@[Link]
Approximate tengrh of watch-keeping sea service (in
months) as: RATIHG
36+ CHIEF MATE

Types of ship served on

LPCi T\NKERS ) BLILK CARRIER
Company & Training Manager WILHELI'(SeN [Link] MN Wili your company be paying your course feesT (Yes/No)
NO
Course Requirements
P{ea5e ind,caLe the date that vou w,sh to .omnrence vour cou.5e of study and 'ti.k' ihe retevani course box{es} below: /Pee].tJ 202-2

oow Exam route: mr'nimum sea NaEST(O) HEt{,{(O)

STCW 95 I/1 Officer of the Watch seMce requiremenl 16 EDH

UCl,lEP Na (M)
Exam route for ex-Cadets Nayigatbn a:ds 6 EquiFTent HEL 4(M)
STCW 95 Chief ,[ate (post HND) with futl HND and 12 monrhs
Ar /2 w/k sea service as OOW

UCMFDP
Exam route for ex-Cadets NaESI(M) HELM(M)
sTcvv 95 Chief tlate (post wi!h futt Foundation Degree
FdSc)
A|/2 and 12 months w/k sea
service as OOW
Exam route ior Officeis wth NaEsT{M)
HND Nautical Science part 1 |leicd6n Ai6 e Equipmnt HELM{M)
STCW 95 Chief Mate & i,{aster
wilh 12 months w/k sea

UMSDlOP l,laster's [Link] Oral Examinatioh (4-week course in preparation for MCA OralExamination)
UMSDRP Dec (lsdepeodent study optjofl - direct tutorjat support can atso be arranged jn

undertaking the Nautical Science examination route) msst have g!9 ofthe
A: HND or HNC Nautical kience Part 1 8: STCW 95 A-ll/1 OOW Certificate of C
As slated above. tndicate A or B: Cotlege Attended Finish Date
Please note: tiibolone ol course tees are due ptior to [Link] start dote- Students are responsible tor the pdynenr fees unless a company lette.
of Sponsotship is presented at the tine of bookins

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 Have you applied for, or obtained, a Notice of Etigjbitjty from the Maririme and Coastguard Agency (MCA)?

Not yel appLied for (tick): Applied for (state date): Obtatned {please attaclt

Pleose note: You are responsible fot obtoinins your own Notice ol Eligibility from the kCA ond where possible this should be don, befote the course start,
Failurc to do so noy prcvent you from completing your coutse of study ondlor .ause [Link] expense or deloy- Pleose olso note that dll relevant
docunentotion, prcof ol entry, [Link] quotificstiofls etc. nust be brought with you to college when enrottins.

Personal Stat€ment Please include what your [Link] goats are, how thjs course wilL ,dvance your care€r goals and any other jnformatioD you consider reievant to

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Booking Form - Application and Attachments

Deposjl paid by Ban k Transfer/ Epayment/ Card payment over phone The totalamount being forwarded is ([ GBP) t 000
My Notice of Eligjb;lity is attached (tjck) x Photocopies of all supporting [Link]"

r NB. ApPlicatins wlll not be [Link] unl6s all [Link] dftuments .re en.l6ed. DepoJits can be patd 6y bank tra.r€r, forher studenti .an use rhe Epaymem synem
httDs://eoavmEnts.$[Link],!k/@et q card [Link] be proc6sed over the phone followlng receipt of. hooking fo.m and all [Link] ddumentJ.
[Link] see the Co(ce and Feo @rdan<e .otes for information on [Link] [Link], ple6e noto th;e ,ay;ents can tak; up to a wek to be prk6re.t and [Link] to your <<o'tnt.

DECLARATION BY APPLICANT
I confirm that I have disctosed information on att previous study in the UK and alt the detaits in this form are correct to the best
of my knowtedge.

I understand and accept that the information given on this form witt be retained by the University in accordance with the
provisions of Data Protection Act 1998 and that personal information about me witl be used for personnet and administrative
purposes and statutory returns. This information may also be transmitted and disptayed on an interoat network for relevant
Southampton 50LENT University business purposes.

I atso understand that, were relevant, I witl not be'issued with a Confirmation of Acceptance for Studies (CAS) untit this form
has been compteted. By signing the apptication I give my permission for Southampton Solent University to verify the
information given in this form with any previous UK institution at which I have studied and/or with the Home Office UK Visas
and lmmigration service.

I confirm I have read and understood the Course Fees & Guidance Notes.

Signature of Appticant # Date \O-i\-z()i-\