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APPLICATION FORM FOR THE DIPLOMA IN IRISH

Completing the application form does not oblige you to accept a place on this course.

	* Necessary Information
*Surname:
*First Name(s):
*Sex:	Female Male
*Date of Birth:
Are you/were you a student of NUI, Galway? If you are/were please enter your Student Registration Number below.
NUI, Galway Student Registration Number:
PPS Number:
*Nationality:
*Country of Birth:
Address for correspondance: (correspondance will be sent to this address - please ensure you can be contacted at this address)
Home Address: (if different from above)
Home Phone:
Mobile Phone:
E-mail:
Please click the appropriate circle:	NUI, Galway Staff Member NUI, Galway Student Other
Please choose your desired Level of the Diploma in Irish:
Leaving Certificate Irish result (if applicable):	Grade: Level:
*Choose the Centre in which you would like to do the Diploma:
If you entered "Another External Centre" please give details here:
Although you are not obliged to do so, if you have a disability or specific learning difficulty you are encouraged to indicate this on the Application Form in order to avail of the appropriate support from the University. Please tick this box (if applicable):
Where did you hear about this Diploma?	Radio Newspaper Word Of Mouth Internet Other
If you clicked "Other", please elaborate here:
	The fee is €990 per year (for the 2012-2013 session). €500 must be paid before the start of the Diploma. The remainder will be due before 1-11-2012. The fee for full time students of NUIG is €200. If you are not a student of NUI, Galway, you will be required to send a birth certificate and a passport-sized photograph to Oifig an Dioplóma (contact details below) before 24-08-2012. Don't forget you must complete the Language Placement Test after submitting this form.This is a test designed to indicate which level will best suit your language needs by testing your language level. You will have the opportunity to do so after completing this application form. Your application will not be accepted until you complete the Language Placement Test. This placement test will assist us in placing you in the appropriate class.

Acadamh na hOllscolaíochta Gaeilge, Ollscoil na hÉireann, Gaillimh T: + 353 (0)91 595101
Nuashonraíodh an leathanach seo 15 / 08 / 2012