Application Form

All fields must be completed in order to process your application.

Please submit the completed form by email to Brian Colleran:

This application form is for use only in relation to the following programmes. Please indicate which programme you are applying for by placing an X in the relevant box:

Programme / Location / Commencing / Select X
Postgraduate IMI Diploma in Management / Cork / March 2017
Postgraduate IMI Diploma in Strategy & Innovation / GALWAY / March 2017
Postgraduate IMI Diploma in Strategy & Innovation / Dublin / April 2017

*For the full set of programme dates, please see our website at www.managementworks.ie/imi.

Section 1: Personal Information

Surname
Middle name
First name
Male / Female
Name by which you prefer to be known
Job title
Date of birth
Email
Direct line
Mobile
Home address
Country of permanent address (prior to the commencement of study) / 1.Ireland 2.United Kingdom
3.EU State other than Ireland/UK 4.Country Outside EU
Current Employment Details /
Company name
Company Address
Correspondence address (address to which you would like to receive course material/results)
Name of human resource manager (if applicable)
Email address of human resource manager
(if applicable)
Parent organisation name (if applicable)
Parent organisation address (if applicable)
Industry sector
Approx number of employees in your organisation (in Ireland)
Is your company a member of a Skillnet
network, if so please state name of network(s)
Educational Qualifications /
Place an X in the relevant boxes
Leaving Certificate / 3rd Level / Postgraduate / PhD
Have you previous studied at IMI? / Yes / No
If yes, please state the name of the programme:
Have you previous studied at UCC? / Yes / No
If yes, please state your UCC number and the title of the programme:
Have you previously studied at any of the following NUI Institutions?
NUI Maynooth / NUI Galway / UCD
If you have, please state the name of the programme:

Section 2: Portfolio of Learning

Instructions:

1.  Outline all of your relevant qualifications. Add additional rows to this table as necessary.

2.  Original result transcripts may be requested at a later stage in your application process.

Qualification / Institution / Years attended / Relevant courses completed / specialisation /
From / To /

Work Experience

Please describe relevant work experience completed in the last 5 -10 years, starting with your current position. Provide as many details of your roles / responsibilities as possible – particularly at managerial level. Describe each position that you have held in a separate row; add additional rows to this table as necessary.

Qualification / Position Held / Dates / Description of role /responsibilities /
From / To /

Work-Related Training

Provide details of any relevant on-the-job training or continuing professional development (CPD) which you may have undertaken in the last 5 years, starting with the most recent. Add additional rows to this table as necessary.

Programme, workshop or event attended / Dates / Details
(Content, format, etc) /
From / To /

How did you become aware of this programme?

Place an X beside all that apply and elaborate where relevant, e.g., name of radio station, event. Important Note: if you were referred by a Skillnet network, please state the name of this network.
Referral from a Skillnet network
Previous ManagementWorks programme
ManagementWorks Event
ManagementWorks Website
ManagementWorks Newsletter
Referral from the IMI
Referral from a membership organisation
Referral from a professional advisor
Referral from another business owner
Referral from a state agency
Local radio
Local newspaper
Trade magazine
LinkedIn
Facebook
Twitter
Search engine (e.g. Google, Bing)
Other

Please submit the completed form by email to Brian Colleran:

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