De Montfort University Faculty of Health and Life Sciences Application and Enrolment Form for: MSc/PgDip/PgCert/Pg Institutional Credits in Quality by Design for the Pharmaceutical Industry (DL) 2015-16 Applicant Checklist Before submitting this form please make sure all sections are completed. Have you included photocopies of your educational certificates? If your first language is not English, have you enclosed proof of your English language proficiency? Have you enclosed your reference? Have you included 2 passport sized photographs and written your name and date of birth on the back of them? Please return the completed form to: Admissions Department De Montfort University Edith Murphy House, Room 0.23 The Gateway Leicester LE1 9BH hls@dmu.ac.uk Faculty of Health and Life Sciences Application and Enrolment Form - Page 1 of 9
Programme Code: H81272 PLEASE COMPLETE ALL THE SECTIONS ON THIS FORM Programme Title: Quality by Design for the Pharmaceutical Industry Faculty HLS How are you studying? Start date: Distance Learning October 14 March 15 Are you graduating this year? Yes No Award Aim Postgraduate Institutional credits Postgraduate Certificate Postgraduate Diploma MSc Have you previously studied at DMU? Yes No If yes, what is your previous student number? P Title First name(s) Surname Previous Surname (if applicable) Date of Birth D D M M Y Y Y Y Gender Male Female Permanent Home Address: Postcode: Personal email: Term Time Address: (if different from home) Home Tel: Mobile Tel: Postcode: Work email: Work Tel: Term Time Type of Accommodation Halls of Residence Parent/guardian Home Own Home Private Rented Other Term Time Council Tax Authority Leicester Blaby Oadby & Wigston Charnwood Hinckley Other (please specify): Emergency Contact (We will inform your contact if your well-being is threatened and you are unable to give instructions) Contact Name Contact Telephone Relationship to You Faculty of Health and Life Sciences Application and Enrolment Form - Page 2 of 9
Country of Normal Residence England Scotland Wales N.Ireland Ireland France Libya China Hong Kong Thailand Greece Poland Nigeria Cyprus Saudi Arabia Germany India Denmark Taiwan USA Pakistan Other (please state): Country of Birth Applicants not born in the United Kingdom please state date of last entry to UK: D D M M Y Y Y Y Nationality (i.e. what is on your passport) British Irish French German Portuguese Ghanaian Dutch Greek Polish Nigerian Taiwanese Libyan Saudi Arabian Cypriot Pakistani Zimbabwean Chinese Indian Italian American Other (please state): Asian or Asian British Bangladeshi Black or Black British African Ethnic Origin Asian or Asian British Indian Black or Black British Caribbean Asian or Asian British Pakistani Chinese Mixed White and Asian Mixed White and Black Mixed White & Black Caribbean African Other Asian Background Other Black Background Other Ethnic Background Other Mixed Background Other White Background White Welsh White Irish White Scottish Information Refused White English Not known White Northern Irish Other please state: Disability/Medical Conditions (please tick all that apply) No known Disability Deaf / Have Hearing Impairment Asthma Diabetes Wheelchair User / Have Mobility Issues Epilepsy Dyslexia / Specific Learning Differences Personal Care Support Blind / Are Partially Sighted Chronic Fatigue Syndrome Mental Health Issues Other (please state below) Repetitive Strain Injury Autistic Spectrum Disorder / Asperger Syndrome Does your disability mean that you have additional support needs? If yes, we will contact Yes No you to determine appropriate support for you. Are you in receipt of Disabled Student Allowance (DSA)? Yes No If you need advice about how to apply for the Disabled Student Allowance (DSA) then please contact Disability Advice and Support on 0116 257 7595 Faculty of Health and Life Sciences Application and Enrolment Form - Page 3 of 9
Previous Higher Education Experience Do any of your parents or guardians have any higher education (HE) qualifications? i.e. degree, diploma or certificate of HE. Yes No Don t know Information refused Qualifications gained post 16 years of age (i.e. AS/A Levels, Scottish/Irish/Welsh equivalents, BTEC, Foundation, Key Skills, IB etc) Year Subject Qualification Type i.e. A-level, BTEC Grade Completed Previous Educational Institution Name: Town/City: Year Left: Faculty of Health and Life Sciences Application and Enrolment Form - Page 4 of 9
All Previous Qualifications please tick ALL the qualifications you have Level 8 Level 3 UK doctorate degree (PhD) EU doctorate degree Overseas, Non-EU doctorate degree BTEC Diploma at Level 3 Mixed Level 3 qualifications subject to UCAS Tariff points Mixed Level 3 quals not subject to UCAS Tariff points Other qualification at level 8 BTEC Certificate at Level 3 Level 7 BTEC Award at Level 3 UK masters degree EU masters degree Overseas, Non-EU masters degree Integrated UG/PG taught masters degree AQA Baccalaureate (Bacc) A-Level or AS Level EU A/AS level equivalent Overseas, Non-EU A/AS level equivalent PG Diploma 14-19 Advanced Diploma (level 3) PG Certificate PG Cert or Prof Graduate Diploma in Education Qual leading to registration with Architects Reg Board Professional qualifications at PG level (ACCA/CIMA) Other taught qualification at Level 7 Taught work at level 7 for Institutional credit Scottish Highers Scottish Baccalaureate International Baccalaureate (IB) Diploma International Baccalaureate (IB) Certificate Cambridge Pre-U Diploma Cambridge Pre-U Certificate MPHARM Welsh Baccalaureate Advanced Diploma (level 3) Level 6 UK degree with honours Foundation at level 3 (FE) (ie. Art & Design) Other Qualifications at Level 3 (i.e. BTEC Nationals, NVQ, GNVQ) EU degree BTEC National Diploma (Incl. Early years )(level 3) Overseas, Non-EU degree BTEC National Certificate (level 3) Degree with honours leading to QTS status BTEC National Award (level 3) Professional qualifications at UG level Level 2 Professional Graduate Certificate in Education 14-19 Higher Diploma (level 2) Other Qualification at Level 6 Welsh Baccalaureate Intermediate Diploma (level 2) Level 5 UK ordinary (non-honours) degree EU ordinary (non-honours) degree Overseas, Non-EU ordinary (non-honours) degree Foundation degree GCSE/O Level Scottish O grades and standard grades Other Qualification at Level 2 (ie. NVQ/GNVQ Intermediate) BTEC First Diploma (level 2) Diploma of Higher Education (DipHE) BTEC First Certificate (level 2) Higher National Diploma (HND) BTEC First Award (level 2) Foundation course at level 5 Level 1 Certificate/Diploma in Education (non-graduate ITT) 14-19 Foundation Diploma (level 1) Other Qualification at Level 5 (i.e. NVQ, BTEC, ACCA/CIMA) Welsh Baccalaureate Foundation Diploma (level 1) Level 4 Other Qualification at Level 1 Certificate of Higher Education (CertHE) Higher National Certificate (HNC) Higher Apprenticeship (level 4) Other qualification at Level 4 (i.e. NVQ, SQA, UCPD) Undergraduate Credits General guidance to levels: Level 1 and 2 - usually taken in secondary education (UK school) Level 3 usually taken in further education (FE college) Other Higher education (HE) Access Course, QAA recognised Higher education (HE) Access Course, not QAA recognised Previous experience and/or admissions test Other qualification level not known No formal qualification Level 4, 5 and 6 usually taken in higher education (University at undergraduate level) Level 7 and 8 usually taken in higher education (University at postgraduate level) Faculty of Health and Life Sciences Application and Enrolment Form - Page 5 of 9
What is your first language? English Language Proficiency If your first language is not English, please give your score for either of the following, if applicable: Please attach evidence of this to your application form: If you have not taken an English language test yet, what date do you plan to take it? What other English language qualifications do you hold? How many years have you studied English language? IELTS score TOEFL score Have you been taught in English in your home country? Yes* No *If Yes, please give details: Supporting Statement Why do you wish to study this course? (Please use additional paper if necessary) Faculty of Health and Life Sciences Application and Enrolment Form - Page 6 of 9
Occupation (please complete one of the below options) Under 21 please list occupation of highest paid parent/guardian 21 or over please list your current or previous occupation. Would you describe yourself as having been in care on or after your 16 th birthday? Yes No Don t know Information refused Employment Background (including current employer) Employer Position Date from/to Reference You should now ask your Line Manager/Employer to provide a reference on letter-headed paper of the organisations they represent, to the address on the front of this form as soon as possible. They should clearly state your name, DOB and course and should be stamped with the company stamp if possible. Emailed references are acceptable provided they are from a professional source. Name Position Referee Information Address Telephone Email Relationship to you Known Since Criminal Convictions The University must know about any unspent criminal offence information about you. Please read the following carefully. If you have any unspent offence(s) to declare please tick the box below. If you tick the box you will not be automatically excluded from the application process. However we may need to contact you for further information about this. Please familiarise yourself with the University s criminal record process - full details can be found within our Admissions Policy on our website at www.dmu.ac.uk. Faculty of Health and Life Sciences Application and Enrolment Form - Page 7 of 9
Fees - You are responsible for your fees irrespective of who is paying. Who is expected to pay fees? Applicant Employer/Sponsor If you are being paid for by your Employer/Sponsor please provide the following details: Company Name: Company Address: Contact Name of person responsible for fees: Contact details Email: Company reference number/purchase order number: Telephone number: If your fees are being paid for by your Employer or a Sponsor, you must have an official letter from them confirming the details of their sponsorship of your studies and the amount they are funding you for. Please return this letter with this application/enrolment form. If you do not have this letter yet, please submit it as soon as possible to the address on the front of this form. Please see below the fee for the programme modules for your information: Module Title Credits* Fees/ ** 1 Principles and Tools of Quality by Design 30 1,450 2 The QbD Product Development Roadmap 30 1,450 3 Quality by Design in Practice 30 1,450 4 Manufacturing, Process Controls and Regulatory Affairs 15 1,025 5 Negotiated Studies (option: e.g. QbD for Biopharmaceuticals) 15 1,025 6 Research Methods 15 1,025 7 Work-based Dissertation 60 2,100 Total available 195 9,525 Total for full MSc 180 8,500 *For the MSc, the students need to complete 180 credits from the 195 credits available. ** Discounts maybe available please contact Dr Walkiria Schlindwein wss@dmu.ac.uk Faculty of Health and Life Sciences Application and Enrolment Form - Page 8 of 9
Data Protection Act Statement, Student Declaration and sharing your Learner Record I understand that by signing this form I am agreeing to be liable for all tuition fees incurred over the duration of my programme of study, in whole or in part, and that if I or my sponsor fail to pay my tuition fees in a timely manner that DMU reserves the right to terminate my studies. I understand that De Montfort University reserves the right to prosecute me in order to recover any debt. I understand that should I wish to leave DMU before the end of my programme of study I am responsible for contacting the University to terminate my enrolment and that I am liable to incur costs equating to up to a full year of tuition fee if my registration is terminated by DMU on my behalf. For students studying at DMU on a visa issued by the UKVI only I agree to abide by the terms of my visa and I understand that should DMU have any concerns about this and/or my attendance on the course, I will be reported to the UKVI. In accordance with the Data Protection Act 1998 the University requires your consent to collect and use personal information. I agree to De Montfort University processing personal data contained in this form or other data which the University may obtain from time to time from me or other people whilst I am a student as listed in the online document How We Use Student data, available on the DMU website at http://www.dmu.ac.uk/studentdatause. I agree to the processing of such data for any purpose connected with my studies, including placements or my health and safety. The Learning Records Service (LRS) programme offers a service to allocate Unique Learner Numbers (ULNs) to students. The ULN enables individuals to access a Learner Record which will offer learners the facility to access their participation and achievement data via a website and to share this with other organisations and individuals where permission is granted. At no time will your personal information be passed to organisations for marketing or sales purposes. Individuals can opt out by ticking this box. More information can be found at www.miap.gov.uk. I declare that the information contained in this form is correct and understand that if I have knowingly given false information I may be excluded from De Montfort University. I agree to abide by the University s regulations. I understand that the programme for which I am enrolling is subject to availability. Signed by Applicant Date D D M M Y Y Y Y Academic Signature: Decision Name Date: Admissions Recorded and acknowledged Date Initials Status - Home/EU/ Overseas ELQ Y/N Photos ID Card Sponsor letter Fees Discount Faculty of Health and Life Sciences Application and Enrolment Form - Page 9 of 9