MiddlesexUniversity

ApplicationForm

OFFICEUSE ONLY

RegionalID/AgencyCode:MISISStudentNumber:

ThisformistobeusedforDirectapplicationsonly

FullTimeUndergraduateapplicationsshouldbesubmittedthroughUCAS.PGCEapplicationsmustbesubmittedthroughtheGTTR

PersonalDetails(Asitappearsonyourpassport/driver’slicenceorotherofficialID)

FamilyName:FirstName:MiddleName(s): Title:(Mr/Msetc) PermanentAddress:

Postcode: Country:TelNo:Email:

Previous Name: Date of Birth: (DD/MM/YY) Gender:MaleFemale

CorrespondenceAddress:(Ifdifferentfrompermanent)

Postcode: Country:Mobile:

Course(s)AppliedFor

ProgrammeTitle: LevelOfStudy:Undergraduate Postgraduate

EntryPoint:Year1Year2Year3

ModeOfStudy:FullTimePartTimeOther:(Specify)

IntakeYear:Month:JanSept

ProgrammeTitle: LevelOfStudy:Undergraduate Postgraduate

EntryPoint:Year1Year2Year3

ModeOfStudy:FullTimePartTimeOther:(Specify)

IntakeYear:Month:JanSept

Disabilities/SpecialNeeds

TheUniversityencouragesyoutodiscloseanydisability/medicalconditionwhichcoulddisadvantageyourabilitytostudy.AlloffersaremadeonacademicgroundsonlyandtheinformationyousubmitwillbeusedtohelpMiddlesexUniversityprovideappropriatesupport.Pleasetickallthatapply.

NoDisability / 0 / LearningDifficulty / 1
Blind/SeriousVisualImpairment / 2 / Deaf/SeriousHearingImpairment / 3
WheelchairUser/MobilityIssues / 4 / PersonalCareSupport / 5
MentalHealthCondition / 6 / UnseenDisability:e.g.Diabetes / 7
AutisticSpectrum/Asperger’s / T / Otherdisabilitynotlistedhere / 9

Pleasedetailotherdisabilityoradditionalsupportneeds:

ResidentialInformation/Visas

Pleaseprovideinformationrelatingtoyournationalityandresidence.AttachcopiesofanypertinentHomeOfficedocumentation.Furtherinformationmayberequested.

Countryofpermanentresidence:

IfUK, pleasegive County/Borough:Countryofbirth: Nationality(asonpassport): IfyouareanonEEA/UKnationalpleaseanswerthefollowingquestions:

Passportnumber(includecopyofphotopagewithADP):HaveyoueverlivedoutsidetheUK/EU? Yes No

IfYes,pleaseindicatedateofentrytotheUK/EU: DoyoucurrentlyhaveaUKVisa? Yes No

IfYes,entertype,expirydateandVisanumber: Haveyoubeengrantedindefiniteleavetoremain?IfYes,enterdate:

FeePayment

Pleaseprovidedetailsofhowyouintendtopayyourtuitionfees.Applicantsmaybeaskedtosupplydetailsoftheirfinancialpositionandtheirprovisionforthepaymentoffees.

WhowillpaySelf-Funded:Yesyourtuition

fees?Employer(pleasespecify): Other(pleasespecify):

IfyouintendtoapplyforaMiddlesexUniversityScholarship/Award,pleasespecify:

HighestQualification

IfyoupreviouslystudiedatMiddlesex University,pleaseenterStudentID:

Pleaseenteryourhighestlevelofeducation,e.g. BSc/MSc: Ifthis award was taken in the UKenter institutionname: Iftakenelsewherepleaseenternameandcountry:

AcademicQualifications

IfyouareanonEEAnationalyoumustgiveALLdetailsofpreviousstudyundertakenintheUK.

Pleaselistallqualificationsinchronologicalorderwiththemostrecentfirst.Providecopiesofcertificates andtranscriptswhereappropriate.Ifnotaccompanyingthisform,pleaseensureanydocumentationissubmittedtotheAdmissionsOffice,clearlystatingtheprogrammeyouareapplyingfor.

Note:Printoutsfromself-service/webportalsystemswillnotbeaccepted.Thedocumentationbeingsubmittedmustbeformallyissuedbytheawardinginstitution/exambody.

InternationalstudentsmustsubmitdocumentationbothintheoriginallanguageandasanofficiallyendorsedEnglishlanguagetranslation.

QualificationsPending
AwardTypeSubject / AwardDate / Grade(IncludingPredicted) / InstitutionAddress / DatesFrom–To
QualificationsAchievedIncludingProfessionalQualifications
AwardTypeSubject / AwardDate / GradeAchieved / InstitutionAddress / DatesFrom–To

EnglishLanguageQualifications

EntryisconditionalontheachievementofastandardlevelofEnglish.IfyourfirstlanguageisnotEnglishpleasegivedetailsofthemostrecentEnglishProficiencycourseyouhavetaken.

IfyourequireaTier4Visa,pleasenotethatyoumustalsobeabletodemonstrateEnglishabilitytotheminimumlevelrequiredbyUKBA.

QualificationName / GradeAchieved / AwardDate

GMAT–GraduateManagementAdmissionTest – if applicable

Verbal / Quantitative / AnalyticalWriting / Total / AwardDate

EmploymentAndWorkExperience(Mostrecentfirst)

Employer’sNameAddress / Role & Brief Description OfDuties / FTorPT / DatesEmployed
Employer’sNameAddress / Role & Brief Description OfDuties / FTorPT / DatesEmployed

Numberofyearsfulltimeworkexperience*(at1Septemberpriortostartofprogramme)

*Pleasedonotincludeparttimework,internshipsorsummerjobs.

PersonalStatement - see Metanoia Institute Application Form

DeclarationOfCriminalRecord

InanefforttohelptheUniversityreducetheriskofharmorinjurytotheirstaffandstudentscausedbythecriminalbehaviourof otherstudentswemustknowaboutanyrelevantcriminalconvictionsanapplicanthas.

Inthismatterrelevantcriminalconvictionsaredeemedonlytobethoseconvictionsforoffencesagainstaperson,whetherof aviolentorsexualnatureandconvictionsforoffencesinvolvingunlawfullysupplyingcontrolleddrugsorsubstanceswherethe

convictionconcernscommercialdrugdealingortrafficking.Convictionsthatarespent(asdefinedbytheRehabilitationofOffendersAct1974)arenotconsideredtoberelevantandyoushouldnotrevealthem(however,seenextparagraph).

Ifyouareapplyingforaprogrammeinhealthorsocialworkwhichmayinvolveworkwithchildrenorvulnerableadults,youMUSTtellusaboutanycriminalconvictions,includingspentsentences,cautions(includingverbalcautions)andbind-overorders.DuetothenatureoftheseprogrammestheyareexemptfromtheprovisionofSection4(2)oftheRehabilitationofOffendersAct1974.

ByvirtueoftheRehabilitationofOffendersAct1974(Exemptions)Order1975andtheChildAct1989,applicantsarenotentitledtowithholdinformationaboutconvictionswhichforotherpurposesare‘spent’undertheprovisionsoftheAct.Ifyouareofferedaplaceononeofthesecoursesandbeforeyoucommenceyourstudies,youwillneedan‘EnhancedDisclosureDocument’fromtheCriminalRecordsBureauortheScottishCriminalRecordOfficeDisclosureService.

HaveyoubeenthroughtheCriminalRecordsBureauEnhancedDisclosureprocessinrelation

toyourcurrentemployment?Yes

IfYes,pleasestatethedateandreferencenumber: Doyouhavearelevantunspentcriminalconviction? Yes

Applicantswhohaveapreviousconvictionwillnotbeautomaticallyexcludedfromtheapplicationprocess.However,ifyouhavetickedYes,pleasedisclosedetailsofyouroffenceandconviction,includingdatesandcourtsconvictedat.Thisinformationshouldbesubmittedalongwithyourapplicationforminaseparatesealedenvelope,clearlymarkedconfidentialwithyournameanddateofbirthonit.AnyinformationdisclosedwillbehandledanddisposedofsecurelybyMiddlesexUniversityincompliancewiththeCriminalRecordsBureauCodeofPractice,theDataProtectionActandotherrelevantlegislation.

Ifyouareconvictedofarelevantcriminaloffenceafteryourapplicationhasbeensubmitted,youmustnotifyus.TheUniversitymayrequestfurtherdisclosurefromyouandyouroffencemayaffectyourapplication.

Checklist

Beforesubmitting this application form,pleaseensurethatallsectionsoftheformhavebeencompletedandwhereappropriatethefollowingitemshavebeenattached.Failuretoincludetheseitemsmayslowtheprocessingofyourapplication.Donotsendoriginaldocumentationatthisstage.TheUniversitywillnotnormallyreturndocumentationsubmittedandwillnotbeheldliablefororiginaldocumentationwhichislostordamagedinanymanner.PleasebepreparedtopresentoriginalcopiesofalldocumentationtotheUniversityatenrolmentforverification.

Copiesofallacademicdocumentationincludingtranscripts,certificates,etc

SyllabusofHigherEducationlevelprogramme(forapplicantsrequestingcredittransfer/topup) PersonalStatement

Referencesasapplicable

PhotocopiesofpassporttoincludephotographandpersonaldetailpagesResume/CurriculumVitaeifapplicable

PhotocopiesofIELTS/TOEFLorotherapprovedEnglishqualificationifapplicableCDPortfolioforArtDesignprogrammes

Declaration

Anystatementsonthisformwhichprovetobeuntrueorpurposelymisleadingwillrendertheapplicationvoid.Furthermoreifinaccuraciesarehighlightedatalaterstageweretaintherighttoretractanyoffermadeorexpelthestudentwithnorefundoffees.

Iacceptandgrantpermissionformyemployer/sponsortobeinformedofanyrelevantinformationrelatingtotheprogressionofmyprogramme,includinganyrecordofattendance.

Iconfirmthattheinformationgivenonthisformistrue,completeandaccurate.Noinformationrequestedorothermaterialhasbeenomitted.IconsenttothestorageandprocessingofthisdatabyMiddlesexUniversityundertheprovisionofthe1998Data ProtectionAct.

Signed:Date:

PLEASERETURNTHISCOMPLETEDFORMTO

MarketingMonitoring

PleaseindicatehowyouheardaboutMiddlesexUniversity:

BritishCouncil/EducationUK / DirectMailFromMiddlesex / Employer / MBAFair
UCASWebsite / MiddlesexWebsite / MiddlesexStudent/Alumni / AMBA
MiddlesexRegionalOffice / TubeStation / Prospects.ac.uk / SocialNetworkingSite
Google / CareersAdviser/Tutor / Push / Other:(pleasespecify)
Newspaper/Magazine / Friend/Family / Whatuni

A)White / B)BlackorBlackBritish / C)AsianorAsianBritish
British / 11 / Caribbean / 21 / Indian / 31
Irish / 12 / African / 22 / Pakistani / 32
Scottish / 13 / OtherBlackBackground / 29 / Bangladeshi / 33
Welsh / 14 / OtherAsianBackground / 39
OtherWhiteBackground / 19
D)Chinese / E)Mixed / F)OtherEthnicBackground
Chinese / 34 / WhiteBlackCaribbean / 41 / NotKnown / 90
WhiteBlackAfrican / 42 / InformationRefused / 98
WhiteAsian / 43
OtherMixedBackground / 49