Part-Time University Education Application Form

Part-Time University Education
Application Form
2016 Entry
1. Course applied for:
2. Date of start:JanSept
3. Name:
Address:
Postcode:
Tel: Mobile:
E-mail address:
Date of birth:
Nationality:
Have you been resident in the UK or EU for the last three years? Y
N
Do you have a disability and/or special educational needs the College or University
should be aware of? Y
N
Do you have any medical or health conditions the College or University should be aware of? Y N
4. Please state qualifications you hold in Maths and English e.g. O Level, GCSE, Functional
Skills etc, including grades and year:
Grade
Year
Maths:
English:
Other academic/professional qualifications (level):
Grade
Year
Part-Time University Education
Application Form
2016 Entry
Qualifications currently being studied
Level
Date due to complete
Location
If your qualifications have been obtained anywhere other than Burnley College then you will
need to produce the certificates for your main qualifications at enrolment.
Have you undertaken study on a university level course previously? Y
If yes, please give details:
N 5. Do you have any criminal convictions? Y
N
(If yes to the above, please give brief details of the conviction including the date.) A further risk assessment may be required. Some courses will also require a Disclosure and
Barring Service (DBS) check to be carried out.
Part-Time University Education
Application Form
2016 Entry
6. Employment History (to date):
Organisation
Position Held
From
Month
Year
To
Month
Year
Details of any other study or experience relevant to the course you are applying for,
including voluntary work:
Please supply details of the person to whom you are passing the reference request:
Referees name (print):
Role/relationship to applicant:
How long have they known you:
Contact details
(including telephone
and email):
FT
or
PT
Part-Time University Education
Application Form
2016 Entry
Further information:
Please state here your reasons for wishing to pursue the course, and give any details of any
other relevant skills, achievements or experience in support of your application. (You may
wish to discuss this section with the HE Support Team before completion).
Continue on a separate sheet if necessary. (Max 500 words)
Declaration: I confirm that the information given on this form is true, complete and accurate
and no information requested or other significant information has been omitted.
I have read the Notes for Guidance for Completion of the Application Form.
Applicant’s signature:
Date:
Please return to: The University Education Team, Student Services, Princess Way, Burnley, BB12 0AN.
“Burnley College
is Outstanding”
Part-Time University Education
Application Form
2016 Entry
Please pass this section on to your chosen referee who is advised to return this independently to the
address on the back of this form as soon as possible.
Reference request
You are invited to supply a reference to help us determine the suitability of the applicant named
below to undertake a University level course at the UCLan Burnley Campus.
Applicant name:
Course applied for:
Please indicate which statement most reflects the applicant by ticking in the relevant box.
Please provide an answer for all statements.
Outstanding
Good
Satisfactory
Reliability
Absence
Punctuality
Meet deadlines
Verbal communication
Written communication
Relationship with others
eg colleagues/service users/customers
Problem solving/initiative
Motivation and commitment
Additional comments on any of the above:
Poor
Unable to comment
Part-Time University Education
Application Form
2016 Entry
What are the main skills and qualities that the applicant possesses?
Yes
No
Not known
Has the applicant got a current satisfactory DBS check?
Please state any reason why you would not recommend the applicant for a place on the course:
Please supply any additional information which you feel would support this application:
Signature:
Referees name (print):
Role/relationship to applicant:
How long have you known the applicant:
Contact details
(including telephone
and email):
Please include official
company stamp or
letterhead where
available.
Please return to: The University Education Team, Student Services, Princess Way, Burnley, BB12 0AN.
“Burnley College
is Outstanding”