Application for Admission to a Postgraduate or Professional Development Degree Programme

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1 NOT TO BE USED FOR UNDERGRADUATE DEGREE PROGRAMMES FOR OFFICE USE ONLY Reg. No. Application for Admission to a Postgraduate or Professional Development Degree Programme 1. Personal details 2. Further Details Surname/Family Name First Name(s) Age Years Months Home Address Male (M) Female (F) Postcode (UK Only) Home contact numbers (inc. STD/Area Code) Tel: Fax: Correspondence Address (if different) Date of Birth DD / MM / YY Disability/special needs (refer to Notes for Guidance) Country of Permanent Residence Country of Birth Nationality If born outside the UK Date of first entry to live in the UK Postcode (UK Only) Contact numbers (if different) Tel: Fax: Previous surname/family Name 3. Details of Higher Degree for which you wish to apply Month and Year in which you wish to start: Residential Category (refer to Notes for Guidance) For health related professionals only NMC PIN Mode of Study: Full-time; Part-time; Open Learning (please specify) Course Title: Please indicate how you heard of these courses Accreditation of Prior Learning If you have completed some suitable prior study, obtained qualifications at an appropriate level, or acquired substantial learning from work or life experience, you may be eligible to claim accreditation which could count towards your chosen programme of study. It is important to seek guidance on eligibility for accreditation prior to commencing your studies. Advice can be obtained from the APL Co-0rdinator (Admissions Office) or Course/Subject Leaders 4. Details of intended Fee Payment arrangements i) I will be paying my own tuition fees - Please tick - Yes No ii) I will be in receipt of a grant or scholarship Yes No (please give details) iii) I will be sponsored by my employer or other organisation (please give details) I am a previous student of the University and will be claiming a fee reduction under the University Postgraduate Scheme Yes Yes No No Previous Course Attended: Dates Attended Physical or other disability or medical condition which might necessitate special arrangements or facilities:

2 5. Educational Background (Institutions attended) From (month & year) To (month & year) FT, PT, or SW 6. Most recent qualifications (including HND, First Degree, appropriate overseas qualifications and all relevant professional qualifications) Type of Qualification Awarding Body Month Year Subject Grade School/College qualifications (including GCE A/AS Levels; BTEC OND / ONC; Adv GNVQ 7. Employment (Please indicate your employment experience including any details relevant to the course for which you are applying) Employer Nature of Work Full-time/Parttime Present Employer (if any) Name Address Dates Tel. No. Previous Employers (continue on a separate sheet if necessary)

3 8. Further Information Please state here your reasons for wishing to pursue the course. Give details of any other relevant skills, such as Information Technology and Research Methods. Indicate any other achievements or experience that will support your application. Students from overseas should refer to their certified level of proficiency in the English Language. (You may wish to discuss this section with the course leader before completion.) Continue on a separate sheet if necessary. 9. Criminal Convictions If you have a criminal conviction please tick the box [ ] [ ] I do not want to be contacted by the University with details of courses or of its other services or products 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:

4 10. Reference Statement by Referee for ( Full Name of Applicant ) : Course Applying for : Name of Referee Post / Occupation / Relationship to Applicant Address Tel. No. (including STD) Fax. No. (including STD) How long have you known the applicant and in what connection Can this reference be discussed with the applicant (please tick) Yes No Can this reference be revealed to the applicant (please tick) Notes for the guidance of referees In order to select those students who will benefit from their chosen programme of study, the University requires a supporting statement from a referee. Continue on separate sheet if necessary. You may use separate official letterhead. Your reference about the applicant should, if possible, cover the following: Suitability for the course Intellectual qualities including previous academic performance and any relevant subject experience through work/study Personal characteristics including evidence of ability to sustain study at level of their chosen course Career aspirations Signed Date (please affix official stamp where appropriate, at the end of the statement) Please return to: Admissions Office University of Central Lancashire Preston PR1 2HE Lancashire UK

5 Part-time Undergraduate Course Application: Planning Statistics Ethnic origin (this information will not be made available to Admissions Tutors for selection purposes) Please choose from the ethnic origin terms printed here the one which you feel most nearly describes your ethnic origin and write its code in the boxes If you have used the code (19), (29), (39), (49) or (80) please describe your ethnic origin using your own words in the space provided: 11 White - British 12 White Irish 19 Other White Background 21 Black or Black British - Caribean 22 Black of Black British - African 29 Other Black Background 31 Asian or Asian British - Indian 32 Asian or Asian British Pakistani 33 Asian or Asian British Bangladesh 34 Chinese or Other Ethnic Background - Chinese 39 Other Asian Background 41 Mixed White and Black Caribean 42 Mixed White and Black African 43 Mixed White and Asian 49 Other Mixed background 80 Other Ethnic background 90 Not known 98 Information refused All the personal information provided above, together with any further information the University obtains, is used to process your application. It may also be used by the University to undertake research to plan or improve our services. In addition, the University may advise you of other study opportunities and services provided by it. If you do not wish to receive this information, please write to Advancement, Foster Building, Uclan (NOT TO BE USED FOR UNDERGRADUATE COURSES OR RESEARCH PROGRAMMES)

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