1. Course Details
Course Title:
Proposed start date: Full-time Part-time
Proposed Year/Level of Entry: Year 1 Year 2 Year 3
2. Personal Details
FOR UNIVERSITY USE ONLY
SITS Applicant No. SITS AoS Code:
Decision Interview Date:
Reject Conditions of offer:
Offer
Signed: (Admissions Tutor/Course Director)
Please return to:
Birmingham City University,
Admissions,
University House,
15 Bartholomew Row,
Birmingham,
B5 JU
This form requests a signicant amount of personal information. This is required so that we can decide on your suitability for the course you are
applying for. The information you provide will be used for this purpose and monitoring of equal opportunities only. It will be treated in condence and
will only be seen by those whose jobs require them to do so.
APPLICATION FORM
Please complete in BLOCK CAPITALS
Title: Mr/Ms/Miss/Mrs etc. Gender: Male Female Other
Date of birth:
First name(s):
Maiden or any other name(s) that you have been known by:
Surname/family name:
Permanent address:
Country: Postcode:
Correspondence address (if different):
Country: Postcode:
Daytime telephone: Evening telephone (if different): Mobile:
Email address: Nationality:
If not born in the UK please state date of arrival to UK: Area of permanent residence:
If you are a member of a Professional Body, please give its name and your Registration Number:
Have you ever studied in the UK before? (If yes, please include a copy of all visas)
What level was your previous study in the UK (please tick all that apply)?
Have you ever studied at Birmingham City University before?
Yes
Yes
No
No
Master’sFoundation Degree
Day Month Year
3. Academic and Professional Qualications
Please enter details of the highest level of qualication you currently hold.
Now please list all other qualications taken, whatever the result, in reverse chronological order ie: latest rst. If you are awaiting the result of
any examination please indicate the date in the results column. Please continue on a separate sheet if necessary.
Qualications, eg: GCSE, HND, Degree,
Access, NVQ, Postgraduate, Master’s,
Professional
Subject/unit From
month/year
To
month/year
Place of study Results
(grade
or band)
CATS points and
level (if applicable)
Qualications, eg: GCSE, HND, Degree,
Access, NVQ, Postgraduate, Master’s,
Professional
Subject/unit From
month/year
To
month/year
Place of study Results
(grade
or band)
CATS points and
level (if applicable)
If you have a 10 digit Unique Learner Number (ULN), please enter it in the box provided.
If you are an overseas student please include your IELTS/TOEFL results below:
IELTS overall band score:
TOEFL internet-based test score:
The University may also accept other approved qualications equivalent to the IELTS/TOEFL test scores.
Please list these above or on a separate sheet if necessary.
4. Employment and Work Experience
Please give details of work experience, training and employment in reverse chronological order.
Nature of work/training Name of organisation Full-time or
part-time
From month/
year
To month/
year
6. Referee(s)
Name:
Address:
Postcode:
Telephone:
Fax:
Email:
Name:
Address:
Postcode:
Telephone:
Fax:
Email:
Name and address of Referee(s):
7. Supporting Statement
Please enter here any further information in support of your application, for example, reasons for choosing the course, your professional career to
date (if relevant) and your current career goals. Please continue on a separate page if required.
5. International Students
Did you use an agent to help you nd this course? Yes No
Agent’s name: Agent’s email:
9. Declaration
I conrm that the information given on this form is true, complete and accurate and that none of the information requested or other material
information has been omitted. I accept that if it is discovered that I have supplied false, inaccurate or misleading information, Birmingham City
University reserves the right to cancel my application, withdraw its offer of a place or terminate attendance at the University and I shall have no
claim against Birmingham City University in relation thereto.
Applicant’s
name:
Applicant’s
signature:
Date:
PLEASE INDICATE HOW YOU HEARD ABOUT THE COURSE (please tick relevant boxes):
Advertisement
Education fair
Previous student
Birmingham City University Course Enquiries Team
Colleague/friend
Internet (general)
Personal enquiry to Birmingham City University
Careers service
Employer
Professional association
Alumni
Current student
Direct mail
Birmingham City University website
Other (please specify):
Do you have any special needs? (please tick). The information you provide will be treated condentially and will not affect judgements concerning your
academic suitability for a course.
A
No disability.
B
You have a social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder.
C
You are blind or have a serious visual impairment uncorrected by glasses.
D
You are deaf or have a serious hearing impairment.
E
You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy.
F
You have a mental health condition, such as depression, schizophrenia or anxiety disorder.
G
You have a specic learning difculty such as dyslexia, dyspraxia or AD(H)D.
H
You have a physical impairment or mobility issues, such as difculty using your arms or using a wheelchair or crutches.
I
You have a disability, impairment or medical condition that is not listed above.
J
You have two or more impairments and/or disabling medical conditions.
8. Disabilities
To the Candidate:
Please ll in your name and course details below, detach and forward this part of the form to your referee for completion.
REPORT ON APPLICANT
Referees should note that the contents of this report may be shown to the applicant on request.
Applicant’s name: Date of birth:
Course applied for:
To the Referee:
I am applying for admission to the above course at Birmingham City University. The University would appreciate your personal impressions of my
intellectual ability and professional skills.
Please comment on my character, quality of previous work, personal strengths and weaknesses, and potential.
(Please use a separate sheet if you prefer).
Signed (applicant): Date:
Name and position:
Institution:
Address:
Country:
Telephone: Fax:
Email:
Postcode:
How long have you known the applicant and in what capacity?
Please comment on the applicants suitability for the course with particular reference to his/her strengths.
How would you rate the applicant in relation to the following? (please tick appropriate boxes)
Motivation
Ambition and drive
Originality and creativity
Problem solving skills
Decision making skills
Time management skills
Oral communication skills
Written communication skills
Numeracy
Excellent Very good Average
Below
average
Unable
to comment
Please add any other comments you feel would be helpful in supporting their application to the University:
Name of referee: Signature of referee:
Date:
Thank you for completing this form. Now please return it to:
Birmingham City University,
Admissions,
University House,
15 Bartholomew Row,
Birmingham,
B5 JU
click to sign
signature
click to edit
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