Electronic Application Form Received Robert John Whittock

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Web Postgraduate Application Form - WEBPGA00067

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ON-LINE POSTGRADUATE APPLICATION FORM   (WEBPGA00067)
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Applicant Details
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Title         : Mr
Surname       : Whittock
First names   : Robert John
Date of Birth : 24 Nov 1975
Former name   :
Gender        : M

Postal Address: AstraZeneca R+D Charnwood
                Preformulation and Biopharm.
                Bakewell Road, Loughborough
                Leicestershire
Postal Code   : LE115RH
Country       : United Kingdom

Tel (Daytime) : 01509 645152
Tel (Evening) : 07779796924

E-mail address: Rob.Whittock@AstraZeneca.com (preferred)


Occupation     : Pharmaceutical Scientist
Employer's Name: AstraZeneca
Address        : AstraZeneca R+D Charnwood
Postal Code    : LE11 5RH
Country        : UK


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Course to be taken at Birkbeck
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Adv Cert Powder Diffraction - using the Internet

Second choice: None

Computing Facilities
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Hardware: PC
Operating System: Windows 95
E-mail client: Microsoft outlook 98
Web browser: Internet explorer 4.0


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Current (or Proposed Concurrent) Studies
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N/A


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Past Studies/Degrees Held
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University        : Cardiff University
Address:          : Dept. Of Chemistry,
Cardiff University,
P.O. Box 912,
Cardiff,
CF10 3TB.
From: 1994 To: 2000
Full- or Part-time: Full-time
degree title      : Bsc. Hons (1997)
Subject           : Chemistry
Grade             : 2-1
Date awarded      : 1997


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School-Leaving Qualifications
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Computer studies A
Biology          B
Chemistry        C

Above are A'Levels.


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Professional Qualifications
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[None entered]


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Professional Experience Relevant to your Application
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[None entered]


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Referees
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REFEREE 1
Name          : Dr Gerry Steele
Address       :  AstraZeneca R+D Charnwood
                Preformulation + Biopharm.
                Bakewell Road, Loughborough
                Leicestershire
Post code     : LE11 5RH
E-mail address: Rob.Whittock@AstraZeneca.com
Position held : Pharmaceutical Scientist
University/Organisation: AstraZeneca

REFEREE 2
Name          : Prof. Harry Heller
Address       : Cardiff University,
                Dept. of Chemistry,
                P.O. Box 912,
                Cardiff
Post code     : CF10 3TB
E-mail address: Heller@cardiff.ac.uk
Position held : Professor
University/Organisation: Cardiff University


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English Language Skills
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Is English your first language? Yes



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General Questions
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How did you hear about Birkbeck?
AstraZeneca - Employer

Did you attend a Birkbeck Open Evening?  No

Other Relevant Information:
A grade A level in computer studies.


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Tuition Fees
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How will you finance your studies?
Employer - AstraZeneca

Nationality: British
EU/EEA National? Yes

Country of permanent residence: UK

Country of residence during the last 3 years:
UK ONLY

Is there a time limit/restriction on your residence in the UK?  Not Applicable

If not an EU national, are you claiming Home/EU fee status on the
grounds of marriage or permanent residence?  Not Applicable or No



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Declaration by the Applicant
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The applicant has agreed to the following declaration:

1) In making this application for admission to the course specified
   above, I acknowledge that any offer of admission I might receive
   is subject to the condition that I fulfil the relevant entrance
   requirements and that I provide, when asked to do so, original
   documentary evidence of holding the academic qualifications and any
   other information listed above. If, having been admitted, I fail
   to fulfil that condition, I undertake to withdraw from the College.

2) Undertaking for full-time students liable for the overseas rate of
   fee:
       I undertake not to make any call upon the College in respect
       of fees or increases thereof, living expenses or other
       expenses arising out of my studies. I undertake to make
       arrangements to have at my disposal sufficient funds to
       enable me to make prompt settlement of fee accounts rendered.

Date of agreement:  28th November 2000


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[Statistical information submitted separately to Registry only]

[System Date: Tuesday, November 28, 2000 at 13:36:13]



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