(Note: This form should be submitted at least 5 full working days prior to departure - fields marked * are required)

Name(s) of traveller(s)*:

Position (e.g. staff, postgraduate student, etc)*:

Nationality of traveller(s)*:

College/School/Institute/University Service Department*:

Ext. No*:

Contact email address*:

Email address for cover note*:

Please complete the following details for each trip.

Purpose of travel*:

Is insurance cover note required for visa application purposes?
Yes No

Will any part of the trip involve holidays?
Yes No

If yes, please provide dates & details
(if applicable)

Information on hazardous activities:
(if applicable)

Information on pre-existing medical conditions
(if applicable see #):

Any other relevant information