Dental Care Professionals Programme

SCHOOL OF DENTISTRY

Dental Care Professionals Programme

Application form for the

Combined Diploma in Dental Hygiene and Dental Therapy

2014 Admission

Closing date for Applications: 31 January 2014

Please complete this form in BLOCK LETTERS with a black pen or in typescript and return to:

Mrs Glenys Wood, DCP Programme Secretary, Room 4.05, 4th Floor, Liverpool University Dental School, Pembroke Place, Liverpool, L3 5PS

Telephone: 0151 706 5046, Fax: 0151 706 5652

All applications will be acknowledged; if you have not received an acknowledgement of receipt of your application after 14 days of having posted it, please contact 0151 706 5046.

Original qualification certificates should NOT be sent with this application, but if you are short-listed, you will be required to bring them with you to the interview.

The application form must be completed in full – any forms which are not duly completed will be returned to the applicant – which could delay your application.

Applicants who are offering alternative qualifications to those listed in the minimum entry criteria must provide evidence with their application form as to the equivalence of their qualifications; failure to do so could result in a delay to your application.

Applicants must hold the minimum entry criteria by the closing date – if this is not the case, applicants will not be invited for interview as we are unable to offer places, subject to passing qualifications.

1Personal Details

Title: (Mr / Mrs / Miss / Ms)
Full name:
Please underline family name or surname by which you wish to be formally addressed
Date of Birth:
Nationality:
(This course is only open to applicants from the UK and European Union)
Sex:
Permanent Address (including postcode):
E-mail Address:
Home Telephone Number:
Mobile Telephone Number:
Work Telephone Number:
Address for Correspondence (if different to permanent address):

2 Academic Qualifications (Only list qualifications for which results are known)

GCSE Qualifications

(please specify when listing a GCSE in English whether you have English Language or English Literature)

Examination / Subject / Level / Grades / Verify
Month / Year / Board / GCSE, CSE etc / (Office use only)

A Level Qualifications

Examination / Subject / Level / Grades / Verify
Month / Year / Board / AS, A2 etc / (Office use only)

Access Course Qualifications

(please attach full details of all modules taken at Level 3 and credits awarded)

Examination / Subject / Grades / Verify
Month / Year / Board / (Office use only)

Dental Nursing Qualifications (NEBDN, NVQ, Radiology, Oral Health, Sedation etc)

Examination / Subject / Level / Grades / Verify
Month / Year / Board / (Office use only)

Are you currently registered as a Dental Nurse with the General Dental Council?

Yes No

If Yes, Registration Number: ______

3Other Qualifications(Indicate here any other qualifications for which you are awaiting results or are currently studying for)

Issuing Body / Qualifications / Place of Training / Exam Date

4Employment (please begin with most recent first – continue on a separate sheet if necessary)

Employer’s name and address / Job Title:
Duties:

From Reason for leaving

Employer’s name and address / Job Title:
Duties:

From Reason for leaving

Employer’s name and address / Job Title:
Duties:

From Reason for leaving

Employer’s name and address / Job Title:
Duties:

From Reason for leaving

5Professional Activities

Course/Conference / Organised by / Date

6Membership of Professional Organisations

Please give details of membership to any professional bodies relating to your application
Organisation / Body / Level of Membership / Membership Number

7Health / Disability/AdditionalSupport Needs

It is important for the University to know about your support needs so that advice can be provided on the availability of any facilities that may be required. We recommend that you contact the School to discuss your needs before you apply. You might also like to visit the University to find out more about access and facilities. If you are a candidate with additional support needs please indicate below (e.g. You have a specific learning difficulty (for example dyslexia); you have a disability that cannot be seen, for example, diabetes,epilepsy or a heart condition).

Please Note:

The Dental School has an obligation to arrange health screening for all prospective dental students. Any offer of a place to study is conditional on completion of a health questionnaire and a satisfactory assessment of Fitness to Train by our Occupational Health Service. This process includes blood tests in accordance with the latest guidance on additional health clearance specified by the Department of Health. You will also be offered some immunisations for your own protection. The information from your questionnaire and screening will be kept in confidence by the Occupational Health Service who will contact you directly to make arrangements for screening once you have firmly accepted your offer of a place to study. You are obliged to declare any disability which is, or may be, relevant to your course of study. Failure to declare relevant information may result in exclusion from this course of study. In cases of mild impairment, which do not constitute a disability, the Dental School will consider requests for assistance sympathetically.

………………………………………………………………………………………………

8 References

Please give below the names and addresses of two referees, including telephone numbers if possible. One of your referees should preferably be a present or past employer or someone who knows you in a professional capacity. References will usually only be taken up after the candidates have been short-listed for interview.

Referee 1 / Referee 2
Name:
In what context does this referee know you:
Address:
Post code:
Contact No:
Email:
May be contacted prior to interview (please tick) / Yes No / Yes No

9Criminal Records Bureau Checks

Have you ever been convicted of, cautioned for or charges with any criminal offences including motoring offences? Conviction includes being put on probation or being given absolute or conditional discharge or being bound over or being given a formal caution. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, this includes convictions which would normally be treated as spent under the Rehabilitation of Offenders Act 1974. (You need not include parking or speeding offences which were subject to fixed penalties).

YES/NO please delete as appropriate.

If YES, please give full information about the nature of the offence, the date of conviction or caution and the sentence on a separate sheet of paper.

10Further Information

In support of your application please give briefly any additional information you consider important including any special interests or activities. Please continue on a separate sheet if necessary.

11 Declaration

I confirm that, to the best of my knowledge, the information given in this form is correct and complete:

Applicant’s Signature ……………………………………….. Date ………………..

Once completed, this form should be returned to:

Mrs Glenys Wood

DCP Programme Secretary

Room 4.05

4th Floor

Liverpool University Dental School

Pembroke Place

Liverpool

L3 5PS

Closing date for applications is 31 January 2014