Application form for Advanced Entry to the BA in Applied Addiction Studies & Community Development 2017/2018

·  Please answer ALL questions on the application form
·  Please submit proof of identity e.g. copy of passport (do not submit original documents)
·  Please provide proof of any qualifications when returning your application (do not submit original documents). If you are under 23 years of age you will need to provide a copy of the parchment received for any qualifications that you hold.
·  All information on this application form is for admission and statistical purposes only and will be treated in the strictest of confidence
·  Please note programmes run subject to sufficient numbers. If a programme does not run a full refund is offered
·  Please note an electronic signature will suffice in section D
·  You should complete this application online and submit to
SECTION A – PERSONAL DETAILS
Surname / ''Click here and type Surname''
Forename(s) / ''Click here and type Forename''
Date of birth / ''DD / MM / YY''
Address for correspondence / ''Click here and type Address''
''Address line 2''
''Address line 3''
''County''
''Country''
Home phone number / ''xxxxxxxxxxxxxxxxxx''
Work phone number / ''xxxxxxxxxxxxxxxxxx''
Mobile phone number / ''xxxxxxxxxxxxxxxxxx''
Email address / ''Click here and type Email Address''
Gender / ''Click here and type your gender”
Country of Birth / ''Click here and type your country of birth''
Citizenship / ''Click here and type your country of citizenship”
Language / 'Is English your first language Yes ☐ No ☐
Disability
(please note that disclosure of a disability will not adversely affect your application in anyway / Do you have a disability
Yes ☐ No ☐
''If yes please give details”
Specific Learning Difficulty
(please note that disclosure of a specific learning will not adversely affect your application in anyway / Do you have a specific learning difficulty
Yes ☐ No ☐
''If yes please give details”

SECTION B – QUALIFICATIONS

Indicate the last Educational Institution you attended (i.e. Secondary School, Irish University, Irish Institute of Technology, Post Leaving Cert College)
Educational Institution / ''Click here and type the name of the last Educational Institution you attended''
Address of Educational Institution / ''Click here and type Address''
''Address line 2''
''Address line 3''
''County''
''Country''
Date of entry / ''DD / MM / YY''
Date of graduation if applicable / ''DD / MM / YY''
Indicate the Highest Qualification Achieved (i.e. Junior Certificate, Leaving Certificate, QQI (Formally FETAC), NCVA, Apprenticeship, Ordinary Degree, Honours Degree, PLC Qualification)
Highest Qualification Achieved / ''Click here and type the qualification achieved

SECTION C– EMPLOYMENT RECORD (MOST RECENT)

Employer Details / Job Title / Duration / Overview of duties
''Click here and type the name of your employer'' / ''Click here and type your job title” / ''Click here and type the duration” / ''Click here and type a summary of the overview of your duties

SECTION D – DECALRATION

I declare that the information given by me in this application is true and accurate and that if accepted I agree to read and abide by the regulations of An Cosán. I understand that An Cosan will treat all information as confidential and will not disclose such information except as permitted by law. Other information provided will be held on computer and will only be used for purposes registered under the Data Protection Act.

Signed: Click here and write your signature. Date: Click here to enter a date.

SECTION E – CHECKLIST

Have you attached a copy of your qualifications Yes ☐ No ☐

Have you attached a copy of your identification Yes ☐ No ☐

Closing date for applications is 26th May 2017. Please return to or post to An Cosán, Kiltalown Village Centre,, Fortunestown Road, Jobstown, Tallaght, Dublin 24

- 2 -