Acadamh na hOllscolaíochta Gaeilge, OÉ Gaillimh

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Application Form - Language, Culture and Traditions of Ireland

	* Required information
*Surname:
*FirstName:
*Gender:	Female Male
*Date Of Birth:
*Nationality:
*Address for correspondence:
Home Address: (if different from above)
Home Phone Number:
Mobile Phone Number:
*E-mail Address:
*Current Institution/College: Please include City/State
*Current Level of Study:	Freshman Junior Sophomore Senior Other
If you selected 'Other' please give details:
*Current GPA:
*Please specify your accommodation preference:
*Are you currently taking an Irish language class at your Institution?	Yes No
If yes, please give course name and Instructor’s name:
*Have you previously taken an Irish language class at your Institution, or elsewhere?	Yes No
If yes, give the name of the Organisation, dates and Level:

Further Information

In the United States:

Helen Maginn,
Institute of Irish Studies,
Fordham University, 310 Dealy Hall,
Bronx, NY 10458
Phone: (201) 994 5932
Email: helenmaginn

gmail.com

In Ireland:

Séamas Ó Concheanainn, Administrator,
Acadamh na hOllscolaíochta Gaeilge,
(National University of Ireland Galway),
Carna, Connemara,
Co. Galway.
Phone: 00 353 (0)95 32834
Email: seamas.oconcheanainn

nuigalway.ie

Acadamh na hOllscolaíochta Gaeilge, Ollscoil na hÉireann, Gaillimh T: + 353 (0)91 595101
Nuashonraíodh an leathanach seo 15 / 11 / 2012