SIR JOHN CASS’S FOUNDATION

LORD MAYOR’S SCHOLARSHIP PROGRAMME

APPLICATION FORM 2011 - 2012

Please read the accompanying guidance notes to check you are eligible to apply before completing this application form. Please answer every question and write clearly in black ink.

ABOUT YOU

Title: Mr Mrs Miss Ms First name/s
Family / Last name
Permanent homeaddress:
Student Number:
Date of birth:
Age:
Place of birth:
Nationality:

London Borough:
Length of time at this address:
If less than three years, please provide details of the other addresses you lived at in the last three years, including the dates you lived there:

Phone number:Email address (please write clearly)
Mobile number:
Term time address if different from above:
Is your permanent home:
One parent homeTwo parent homeWith guardian/s
With friendsWith a partnerBy yourself
or spouse
Other, please specify

Type of home: FlatHouseOther, please specify
How many bedrooms:
How many people live there:

YOUR FAMILY

Number of brothers and sisters who live with you: Their ages: Their ages:
How many of these are still in education:
If you have children please tell us:
How many children you have: Their ages:
Are you a single parent? Yes No
Your household income
If you live with you parents please list all their income below(including wages, different types of benefits, maintenance payments etc).
If you live independently of your parents and live with a partner/spouse please list all their income below.
Who
e.g. self, mother, partner etc / Type of income
e.g. salary, pension, benefits / Amount they get before deductions
State whetherweekly, monthly or annually

YOUR EDUCATION SINCE THE AGE OF ELEVEN

From / To / Name and address of school(s) and/or college(s) / Subjects studied / Qualifications/Grades
In order for your application to be considered, a copy of your UCAS form is required. Please enclose a copy if available, or if you do not have a copy, please tick the box to give permission to City University London to provide the Sir John Cass’s Foundation with our archived copy of your UCAS form.
“I confirm that I give permission to City University London to provide Sir John Cass’s Foundation with a copy of my UCAS form.” (please tick)

COURSE APPLIED FOR/CURRENT COURSE AT CITY UNIVERSITY LONDON

UCAS Code: / Course Title:

YOUR EMPLOYMENT

Current and previous employment, voluntary work and work experience
From / To / Position/Job Title / Name of Employer / Type of employment
paid, voluntary, work experience
Please tell us about any voluntary work you listed above

Other Funding

Other Charities, Trusts, Foundations or Funds you have applied to for funding
Name of organisation / Date applied / Result, if known

YOUR STATEMENT

Please use the space below to write your personal statement to support your application. It is important to the bursary committee for you to include information about your interests, your academic and career plans, your family circumstances, any special reasons why you think you should be considered for an award and any other information that you feel might be useful or interesting. You may add an additional page to this application if required.

DECLARATION

The information I have given on this form is complete and accurate to the best of my knowledge and belief:

Signed

Date

Please return your completed application form to:

Tom Pearson

Student Centre Level 2

City University London

Northampton Square

London

EC1V 0HB

DOCUMENTS YOU NEED TO SEND US WITH YOUR APPLICATION

Please enclose photocopies of the following:

your most recent SFE assessment letter

correspondence regarding any applications you have made for Access to Learning funds or other college awards – e.g. scholarships or bursaries

proof of your parents’/guardian’s/partner’s income if you do not yet have an assessment letter from SFE (wage slip, copy of P60, benefit letters, child benefit letter)

proof of your own income if you do not yet have an assessment letter from SFE

Please enclose original copies of the following:

a reference from a current or recent academic tutor

a second suitable reference(for example UCAS, employer or other independent person)

If you think you qualify, please send your completedapplication form with the documents listed above to:

Please return your completed application form to:
Tom Pearson
Student Centre Level 2
City University London
Northampton Square
London
EC1V 0HB

SIR JOHN CASS’S FOUNDATION

ESTABLISHED 1748

INDIVIDUAL GRANTS 2011/12

ETHNICITY/DISABILITY MONITORING

We would be grateful if you would complete this form indicating which of the following options best applies to you. This form helps the Foundation ensure it is receiving applications from all sections of the community. Information you provide is for monitoring purposes only and is not used in the assessment of your application.

Family / Last Name / First Name/s
I am: Female / Male
Nationality / Date of Birth

I would describe my ethnic origin/heritage as (please tick):

Black, African heritage
Black, Caribbean heritage
Black, Other
Bangladeshi
Indian
Pakistani
Asian, Other
Mixed Race
White, European
White, UK heritage
White, Other
Any Other Ethnic Group – e.g. Turkish, Iranian etc
Prefer not to say
I am dyslexic / Yes / No
I have a disability other than dyslexia / Yes / No / I am registered disabled / Yes / No

DATA PROTECTION ACT

I agree that the information given on this form may be processed by the Foundation in accordance with the Data Protection Act, in particular, for the purpose of equal opportunities monitoring. I agree to the storage of this information on manual and computerised files and understand that this information is used for monitoring purposes only.

Signature / Date