E-Mail:
FIRST YEAR DIRECT ENTRY APPLICATION FORM 2016/’17
SURNAME:
OTHER NAME(S):
TITLE (if desired)Date of Birth:
(e.g. Ms., Mr., etc.)(ddmmyyyy)
HOME
ADDRESS
TEL. No. Mobile:Home:
(Note: If you have a different address for correspondence, please provide on separate sheet)
COUNTRY NATIONALITY:
OF BIRTH:
E-MAIL ADDRESS:
CAO NO.
(if you applied forPPS
courses through CAONO.
this year)
Do you have a Disability/Specific Learning Difficulty? Disability/SLD
If relevant, please tick () this box
EMERGENCY Relationship Name:
CONTACT DETAILS (e.g. Mother,Father): (Please Print)
FOR NEXT OF KIN:
Tel. Mobile: Home:
COURSE CHOICES:
Preference Course CodeCourse Title
1
2
Republic of Ireland Examination Details:
YearExam. No. Year Exam. No. Year Exam. No.
LEAVING
CERTIFICATE
Please attach documentary proof of your Leaving Certificate Results, and/or any other previous examinations which may be relevant to this application.
From: To:
NAME AND ADDRESS
OF SECOND-LEVEL
SCHOOL(S)
ATTENDED:
Other Examinations/Qualifications
SPECIAL CATEGORY: Please tick () whichever of the following applies in your case (if any), and give a detailed account for each in the box provided below, and also attach documentary proof of any previous qualifications:
A GCE/GCSEB OTHER EXAMSC FETAC Level 5/6
D FURTHER E HIGHERF MATURE
EDUCATION EDUCATION
DETAILED ACCOUNT:
I hereby certify that the particulars given in this application are true and complete, and that if I am admitted as a student I will abide by the regulations of the Institute. I attach herewith documentary proof of all previous examinations relevant to this application.
SIGNED:DATE:
Completed Application Form should be returned to the most appropriate Office by 31st August, 2016:
Admissions Office, Limerick Institute of Technology, Moylish Park, Limerick
Tel: +353 61 293853Fax: +353 61 293001E-Mail:
OR
Student Administration Offices, LIT Tipperary, Nenagh Road, Thurles, Co. Tipperary
Tel: +353 504 28072Fax: +353 504 28001E-Mail:
Limerick Institute of Technology is a registered Data Controller and will comply with its obligations under the existing or future Data Protection Acts and Freedom of Information Legislation with regard to the dissemination of personal information to any third party. The Institute may provide information to relevant authorities, such as QQI (Quality & Qualifications Ireland), HEA (Higher Education Authority), CAO (Central Applications Office), Grant Awarding Bodies, other Colleges and Research Institutes and Research Collaborators, the Department of Education & Science, and other relevant authorities such as: the Department of Social Protection, the Department of Justice and Equality, and the Department of Health and Children.
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