FSQ_Imperial

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IMPERIAL COLLEGE LONDONFee Status Questionnaire

The College takes great care in assessing fee status and the purpose of thisform is to assist us in determining your fee classification and the informationyou provide will be used SOLELY for this purpose. Please take care to answerall questions which are appropriate to your circumstances and provide fullresponses, including the provision of documentary evidence where requested.Where documentary evidence is required, please send copies - original

documents may be requested at a later stage. Where there is not enoughspace for you to respond to a question, you may attach a separate sheet.

PLEASE REFER TO THE COLLEGES GUIDANCE ON FEE ASSESSMENTREGULATIONS WHEN COMPLETING THIS QUESTIONNAIRE

SECTION A: Personal Details - ALL APPLICANTS

1) Surname/family name:

Forename/other names:

2) Date of birth:

3) Course applied for/registered for:

4) Year of entry:

5) Undergraduates UCAS serial number:

Postgraduates Application reference number:

6) Have you studied at Imperial College before? YES/NO

7) Your current permanent address:

8) Have you lived continuously at the above address for the last three years (apart from normal holidays)?YES/NO

If NO, please give details of other places of residence [including school], with approximate dates:

Town Country From To

For office use only

Fee status:

Assessor:

Date:

Notes:


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9) Parents current permanent address(es):

Father: Mother:

10) Have both of your parents lived continuously at the above address(es) (apart from normal holidays) for thelast three years? YES/NO

If NO, please give details of their places of residence, with approximate dates:

Mother/Father/Both Town Country From To

11) Nationality:

Applicant:A copy of the relevant page(s) of your passport(s) MUST be provided

Father: Mother:

12) Do any members of your family, other than your parents, have EU nationality?[See Guidance on Fee Assessment Regulations for details of relevant family members]

YES/NOIf YES, please detail and provide appropriate evidence:

13) Are any members of your family EEA or Swiss nationals who have worked in the United Kingdom?[See Guidance on Fee Assessment Regulations for details of relevant family members]

YES/NO

If YES, please provide further information and appropriate evidence:

14) In which country are you currently living?

Have you lived in the above country continuously since birth (excluding holidays)? YES/NO

If NO, please give details of the countries in which you have lived, with approximate dates for each:

Country From To


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15) If the answer to question 14) is NO, please outline the main reason for living in each of the countrieslisted:

Country Main purpose of residence

Please provide any relevant documentary evidence

16) If you are already in the UK but were not born here, what was the date of your first entry to the UK?Documentary evidence must be provided, e.g. a copy of the passport stamp

______/______/______day month year

SECTION B: Immigration Status in the United Kingdom NON-EU NATIONALS ONLY

17) Are there any restrictions on your stay in the UK? YES/NO

If YES, please state what the restrictions are:Documentary evidence must be provided, e.g. a copy of the relevant pages of your passport

18) Do you have Indefinite Leave to Enter/Remain in the UK? YES/NO

If YES, please give the date on which it was granted: ______/______/______day month year

Documentary evidence must be provided, e.g. a copy of the relevant pages of yourpassport/Home Office letter

19) Have you, your parent(s), or spouse/civil partner been granted asylum or recognition as a refugee (underthe United Nations (Geneva) Convention 1951) by the UK Government? YES/NO

If YES, please give details of the person recognised:

Documentary evidence must be provided. Please note: if the person recognised is your parent orspouse/civil partner you must also provide evidence of your relationship with that person (e.g.a copy of your birth/marriage certificate)

20) Have you, your parent(s) or spouse/civil partner had an application for asylum or recognition as a refugeerejected by the UK Government and nevertheless been granted Exceptional Leave to Enter or Remain(ELE/ELR) or Humanitarian Protection/Discretionary Leave (HP/DL) in the UK? YES/NO

If YES, please give details of the person to whom this has been granted:

Documentary evidence must be provided. Please note: if the person to whom this has beengranted is your parent or spouse/civil partner, you must also provide evidence of yourrelationship with that person (e.g. a copy of your birth/marriage certificate)


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21) If you have answered YES to Question19) or Question 20), and the person named is not yourself, has thatperson lived in the UK continuously (except for normal holidays) since the date or recognition or thegranting of ELE/ELR or HP/DL? YES/NO

If NO, please give details of any absences from the UK:

SECTION C: Additional Information and Declaration ALL APPLICANTS

Additional InformationIt is recommended that you give below any additional information about yourself, your family or your circumstanceswhich you believe to be relevant, particularly where it is not covered by your answers to questions elsewhere onthis form. You may continue on a separate sheet if necessary.

DECLARATIONThe information I have supplied is, to the best of my knowledge and belief, accurate and complete. I undertaketo inform you immediately if there is any material change to my circumstances which I believe may affect my feeclassification

SIGNED --------------------------------------------------------------------------- Date: ---------------------------------------

Note: EU Member States areAustria, Belgium, Bulgaria,, Cyprus, Czech Republic, Denmark, Estonia, Finland,France, Germany (excluding Buesingen), Greece, Hungary, Ireland, Italy (excluding Camione dItalia and

Livigno), Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal (excluding Macao),Romania, Slovakia, Slovenia, Spain, Sweden, and the United Kingdom (excluding the Channel Islands andthe Isle of Man).

EEA Member Statesare as above plus Iceland, Lichtenstein and Norway.March 2007

Documents

FSQ_Imperial