Admission conditional on:

FOR UNIVERSITY USE ONLY

Ack. Interview:

Admission conditional on:

Academic Signature:

Date:

FINAL:

Application for Admission to London or Birmingham

	APPLICATION NUMBER

(Please Type or Print in BLACK ink)

1. PERSONAL INFORMATION

Mr/Mrs/Miss/Ms	FORENAMES	SURNAME	PREVIOUS SURNAME (IF ANY)
Sex (M/F)	Marital Status	DATE OF BIRTH	NATIONALITY	Leave Blank Code	COUNTRY OF BIRTH	SCHOOL/COLLEGE/UNIVERSITY LAST ATTENDED AS A FULL TIME STUDENT	Leave Blank Code
DISABILITY/MEDICAL CONDITION: If you have a disability or a medical condition which affect your studies and for which special arrangements might have to be made please provide full details below.	Leave Blank 0-9
PERMANENT HOME ADDRESS	POSTCODE
ADDRESS FOR CORRESPONDENCE (if different to permanent address)	POSTCODE
HAVE YOU BEEN ORDINARILY RESIDENT IN THE UK/EU (i.e. without any restriction on the period you may remain in the UK/EU) FOR THE PAST 3 YEARS FOR PURPOSES OTHER THAN EDUCATION? YES / NO (Delete as applicable)
DOMICILE CODE (LEAVE BLANK)	HOME TELEPHONE NUMBER	DAYTIME TELEPHONE NUMBER	FAX NUMBER or EMAIL ADDRESS

2. COURSE TITLES
Please write title(s) of course(s) you wish to study, in full, as listed in the prospectus. There is no order of preference.

COURSE TITLE	CAMPUS (tick box)
LONDON	BIRMINGHAM
1.
2.
3.
DESIRED ACADEMIC YEAR OF ENTRY (e.g. 2013/14)	DESIRED MONTH OF ENTRY (e.g. September 2013)

3. ACADEMIC / PROFESSIONAL QUALIFICATIONS

School, College, University or Professional Body	Dates	Qualification	Grade / Classification	Subjects
Successful applicants will be required to produce documentary evidence of qualifications

4. EXAMINATIONS TO BE TAKEN

Examination Body	Date	Level	Subjects

5. OVERSEAS APPLICANTS

APPLICANTS WHOSE FIRST LANGUAGE IS NOT ENGLISH MUST PROVIDE THE FOLLOWING WITH THIS APPLICATION:

(i) Evidence of proficiency in English Language

(ii) Name and address of person or organisation guaranteeing financial support

6. EMPLOYMENT

Give a brief history of your employment (including recent temporary or vacation employment)

Present Post (title)	Dates	Organisation	Responsibilities
Previous Posts	Dates	Organisation	Responsibilities

7. FINANCE

This section should be completed only by applicants wishing to register as full-time students.

If you intend to apply for financial support please indicate to which grant awarding body application will be made.

...........................................................................................................................................................................................................................

If you do not obtain a grant will you be able to proceed with your application?

YES / NO (Delete as appropriate)

8. ADDITIONAL INFORMATION

State your reason for applying and provide any further information which you would wish to give in support of your application (e.g. attendance on short courses, experience, career development, ambitions etc.)

CRIMINAL CONVICTIONS
Do you have any criminal convictions? YES □ NO □ (If you do not tick either the Yes or No box, we will not process your form).

(not including a motoring offence for which you received a fine or three penalty points).

An applicant for admission to the University who, at the time of application, has been convicted of a criminal offence must declare this. An applicant who is convicted after applying and before the date of admission must inform the University without delay.

9. EMPLOYMENT CLASSIFICATION (tick which sector you work in – if applicable)

Agriculture, Forestry, Fishing		Transport and Communication
Energy and Water Supply Industries		Banking, Finance, Insurance
Engineering		Central Government
Other Manufacturing		Local Government
Distribution, Hotel, Catering		Health Service
Other (please specify)		Education (please state type)

10. COURSE PUBLICITY

Tick the appropriate box to indicate how you learned about the course for which you are applying.

Prospectus		Employer
Newspaper Advertisement		Professional Body
Television		Personal Recommendation
Radio		Other (please specify)

11. REFEREES

Give the names of two persons who may be contacted regarding your academic work and/or employment.

Referee 1	Referee 2
Name		Name
Position		Position
Address		Address
Telephone		Telephone

12. SIGNATURE OF APPLICANT

I consent to the University processing the information on the form for administrative purposes, including consideration of my application, but only insofar as it is permitted to do so within the constraints imposed by the Data Protection Act 1998. In particular, I understand that the University may continue to process this information even if I am refused admission or if I should decline an offer of admission. The information which I have provided on this form is complete and accurate.

SIGNED....................................................................... DATE........................................................................

Дата добавления: 2015-11-04