Professional Short Courses
Application Form
This form is to be used for Professional Short Course applications only.
Personal Details (As it appears on your passport/driver’s licence or other official ID)Family name: / First name(s):
Previous name: / Gender: / Male / Female
Date of birth: (DD/MM/YY) / Title: (Mr/Ms/Mrs etc)
Correspondence address:
Postcode: / Country:
Tel no: / Mobile:
Email:
If you are currently a student at a university or college, please complete the following section:
Name of University:
Current year of study: / 1st / 2nd / 3rd / 4th / Other:
Programme title:
If you are a current or past Middlesex University student (including Summer School), please provide the following:
Student number: / Campus:
Programme of study:
Highest Qualification
Please detail the highest level of qualification e.g. GCSE, A’ Level, BA, MA you have achieved:
Qualification type:
Name of institution and country:
Employment
If you are currently in employment please provide your job title:
Course Applied For
Title:Course code:
Disabilities/Special Needs
The University encourages you to disclose any disability/medical condition which could disadvantage your ability to study. The information you submit will be used to help Middlesex University provide appropriate support and will not affect your application. Please tick all that apply.
No disability / DyslexiaBlind/partially sighted / Deaf/hearing impairment
Wheelchair user/mobility issues / Personal care support
Mental health difficulties / Unseen disability: e.g. Diabetes
Autistic Spectrum/Asperger’s / Other disability not listed here
Please detail other disability or additional support needs:
Accommodation
If you need accommodation for the duration of the course, rooms in our Halls of Residence (Platt Halls) are available at £29 per night. To book a room, please directly contact Viridian Housing:
Course Fees
Please note that applications should be accompanied by payment in full.
Total due: £Cheque/Banker’s Draft made payable to Middlesex University
Cash (in person at a Middlesex University campus finance office)
Credit/debit card – charge my: / Mastercard / Visa / Maestro / Switch / Electron / Solo
Name of cardholder:
Card number:
Start date: / Expiry date: / Issue number (if applicable):
Amount: £
Signed:
Alternatively you can call us on +44 (0)20 8411 5782 to process your payment.
Ethnic Origin/Equal Opportunities Monitoring
The University is committed to providing equal opportunities for all. To assist us with our monitoring please choose one selection from the bold options A–F to indicate your ethnic group. Then tick the appropriate box immediately after this grouping to indicate your cultural background.
This form will be separated from your application and the information supplied will be recorded on our computer system for statistical monitoring purposes. This information will not be considered as part of the admissions process.
A) White / B) Black or Black British / C) Asian or Asian BritishBritish / 11 / Caribbean / 21 / Indian / 31
Irish / 12 / African / 22 / Pakistani / 32
Scottish / 13 / Other Black Background / 29 / Bangladeshi / 33
Welsh / 14 / Other Asian Background / 39
Other White Background / 19
D) Chinese / E) Mixed / F) Other Ethnic Background
Chinese / 34 / White & Black Caribbean / 41 / Not Known / 90
White & Black African / 42 / Information Refused / 98
White & Asian / 43
Other Mixed Background / 49
How Did You Hear About Our Professional Short Courses?
Google Search
Middlesex University Website
Other Website (please specify)
HotCourses
Word of Mouth
Other (please specify)
Declaration
•I confirm that the information given in this form is true, complete and accurate: no information requested or other material information has been omitted. I consent to the processing of this data by Middlesex University for educational purposes under the provision of the 1998 Data Protection Act.
•I understand that I will not be able to enrol or attend classes until full payment has been made.
•I understand that Middlesex University reserves the right to cancel or amend any short courses for reasons of viability or due to any other unforeseen circumstances, in which case any fees paid will be refunded in full.
Signed: / Date:Please Post Or Email This Completed Form To
Anita Mascarenhas / Tel: +44 (0)20 8411 5782
Middlesex University
The Burroughs
London
NW4 4BT
United Kingdom / Email:
Web: