Please write clearly, with names and addresses in BLOCK CAPITALS
1 Programme of study:
Start date Month Year Full-time Part-time Distance-learning
3 Fees/sponsorship:
Who is expected to pay fees? Applicant Local Education Authority Research Council
Employer Sponsor/Parent/Guardian Other (please specify)
Name and address to which fee invoice is to be sent (if other than applicant)
If your attendance at the University will be conditional upon the agreement of your employer, please tick
P.T.O.
2 Applicant’s details:
Title Mr Mrs Miss Ms Dr Other (please specify)
Surname Other names
Gender (tick one) Male Female Date of birth Day Month Year
Permanent home address
Postcode
Telephone Mobile
Email
Address for correspondence (if different from above)
Postcode Agent’s reference number
To be used until Unless other instructions are given, subsequent correspondence will be sent to the permanent home address
Telephone Mobile
Email
Nationality Country of birth
Country of permanent residence
Applicants not born in the United Kingdom please state date of last entry to the UK
Day Month Year
Application Form for Admission to a
Taught Postgraduate Programme
(except LPC/PGD Law)
Alternatively you can apply on-line at
dmu.ac.uk/study/applicants/pg/process/index.jsp
4 Education: school since the age of 11
Schools attended Date started Date finished Examinations taken and Grade Date
qualifications obtained
Education: since the age of 16
Institutions attended Date started Date finished Examinations taken and Grade Date
qualifications obtained
Examinations to be taken/with results Grade Date
pending (give subject and qualification)
6 References You should now ask your referees to provide their references on letterheaded paper of the organisations they represent, to the
address in Section 13 as soon as possible. They should clearly state your name, DOB and course and should be stamped with the company stamp
if possible. At least one referee should be an academic one, Emailed references are accectable provided they are from a professional source.
First referee
Name Position
Address
Telephone Email
Second referee
Name Position
Address
Telephone Email
5 Employment experience
Present position Date of appointment
Workplace address
Telephone
Name and address of employing body (if different from above)
Telephone
Details of previous posts held From To
7 Supporting statement
Why do you wish to study this course? (Please use additional paper if necessary)
9 Disability
Please choose from the list below the statement which is most appropriate to you:
000 You do not have a disability, nor are you aware of any additional support requirements
010 You have dyslexia
020 You are blind/partially sighted
030 You are deaf/have a hearing impairment
040 You are wheelchair user/have mobility difficulties
07
0 You have an unseen disability (eg diabetes, epilepsy, asthma)
080 You have two or more of the above difficulties/special needs
090 You have a disability not listed above (please give details on a separate sheet)
Does your disability mean that you have additional support needs? Yes No
If yes, we will contact you to determine appropriate support for you.
8 English language proficiency
What is your first language?
If your first language is not English, please give your IELTS score or
TOEFL score (if applicable)
If you have not taken an English test yet, what date do you plan to take it?
Day Month Year
What other English language qualifications do you hold?
How many years have you studied English language?
Have you been taught in English in your home country? Yes No If yes, please give details
White
British 11
Irish 12
Other white background 19
Black or black British
Caribbean 21
African 22
Other black background 29
Asian or Asian British
Indian 31
Pakistani 32
Bangladeshi 33
Chinese 34
Other Asian background 39
Mixed
White and black Caribbean 41
White and black African 42
White and Asian 43
Other mixed background 49
Other ethnic background 80
Not given (UK domicile) 90
Overseas domicile 99
Tear off slip Application ref no:
Planning statistics
Ethnic origin (please note that this information WILL NOT be made available to
Admissions Tutors for selection purposes)
Complete this section only if you have shown in Section 2 of the form that your area
of permanent residence is in the UK.
Please choose your ethnic origin and write its code in the boxes.
11 Market research
In order to assist us to market our courses more effectively, could you please specify how you came to
hear of our course? Please tick one box.
Prospectus TV advert Careers office Careers fair Radio advert
Own initiative Press advert Other (please specify)
12 Criminal convictions
You must declare if you have a relevant criminal conviction, including violence against the person or
drug dealing. If you tick the ‘Yes’ box, the University may ask you for further details.
Ye s
Please note that if you are convicted of a criminal offence while your application form is being processed, you should
notify the University immediately.
13 Declaration
I declare that, to the best of my knowledge, the information I have given above is correct in every detail.
If enrolled, I agree to abide by the regulations in force at the time.
Applicant’s signature Date
The completed application form should be returned to:
The Academic Registrar, De Montfort University, The Gateway, Leicester LE1 9BH
Checklist for additional information to send with your form or as soon as possible afterwards:
Proof of English language proficiency Certificates and/or transcripts of your academic qualifications
Reference forms Other
FOR REGISTRY USE
Recorded and acknowledged Date Initials
Status checked/questionnaire sent Date Initials
1 Original course:
CONDITIONAL ON:
Changes YOE Changes SOE
Init Date Reg Date
OR REJECT OUTRIGHT
OR REJECT and CHANGE COURSE (Go to box 2)
Init Date Reg Date
OR UNCONDITIONAL
Init Date Reg Date
Reg use
Overseas Uncond Cond
Why? DEP/ENG
DECISIONS AFTER RESULTS
Changed YOE Changed SOE
ACCEPT
OR
REJECT
OR
CHANGE COURSE (Go to box 3)
Init Date Reg Date
P76 Sent
2 Changed course:
CONDITIONAL ON:
Changes YOE Changes SOE
Init Date Reg Date
OR UNCONDITIONAL
Changes YOE Changes SOE
Init Date Reg Date
Reg use
Overseas Uncond Cond
Why? DEP/ENG
DECISIONS AFTER RESULTS
Changed YOE Changed SOE
ACCEPT
OR
REJECT
OR
CHANGE COURSE (Go to box 3)
Init Date Reg Date
P76 Sent
3 (Further) changed course:
CONDITIONAL ON:
ACCEPT
Changed YOE
Changed SOE
Signed
Date
Reg Date
P76 sent
Further changes after UF stage
Course
YOE
SOE
Signed
Date
Reg Date
© THESTUDIO Marketing Department, De Montfort University, June 2008 (DMU895) All rights reserved.
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