Application form for three year Professional Licentiate in Acupuncture (Lic.Ac.)

Please complete this application form and submit it using our ‘Contact Us’ page or email directly to . Alternatively you can simply print out and post it to the address at the top of our website.

The boxes will expand as you type, and in the case of the tables, if you have filled in the last box simply hit your TAB button, and another line will be generated. If you need any assistance completing this form, please email, or call us on 01926 730284

Please note: Any personal information you give to us will be processed in accordance with the UK Data Protection Act 1998.The information which you give will be used for the following purposes: to enable us to create a computer and paper record of your application; to enable the application to be processed; to enable us to compile statistics, or to assist other organisations such as accrediting bodies to do so, provided that no statistical information that would identify you as an individual will be published. The information will be kept securely, and will be kept no longer than necessary.

1) Personal details

First names: / Surname:
Age: / Date of birth: / Gender:
Home address:
Phone home:
Phone mobile: / Email:

2) Education history (start with highest/most recent)

Qualification/subject / Where attended / From/to / Grade

You will be required to bring copies or originals of certificate/s for your most recent qualifications to interview

3) Informal education – CPD courses etc. (most recent first)

Title of course/workshop / Where attended? / Date gained

4) Are you a member of any professional bodies?

If yes, please detail in box below:

5) Work history – please detail all jobs you have done, paid or unpaid

Dates / Description of the work

6) Working hours – please tell us your current working hours (e.g. full-time, two days per week etc.) Do you have an element of flexibility in your hours, and/or do you plan to cut down during your studies with us?

7) What brings you to study acupuncture now? Please tell us why you want to study acupuncture, including experience as an acupuncture patient,relevant life experience, informal work experience or studies (write up to 500 words)

8) Disability and fitness to practice

Are you a registered disabled person?: (Yes/no)
If yes, please state the nature of your disability:
Registration number (if applicable):
If you are not registered disabled, but have a disability that you would like us to know about, please provide brief details:
Please tell us about any adjustments or support (if any) that you may require in order to complete your studies:
Please note that The Academy operates a widening participation/equal opportunities policy, and will consider applications from people with a disability as long as basic fitness to practice criteria are met

9) Preferred cohort (please state March or September followed by the year)

10) Are you planning on applying for a Career Development Loan as part funding for the course? (please state yes or no)

This information is for admin only, and you can change your mind at a later date!

11) Self-declaration of criminal record

Before making your declaration, please note that convictions normally considered ‘spent’ must also be declared.
Please answer with either YES or NO in the boxes:
Have you ever been convicted of a criminal offence?
Have you ever been cautioned for a criminal offence?
If you have answered ‘yes’ to either of the above, you may wish to write a brief statement in support of your application and place this in a sealed envelope (marked ‘confidential, for the attention of Admissions’ and bring it for consideration at interview.

12) References

Please list the names and email/telephone details of two people (not relations) who have known you for a minimum of three years and are prepared to give a reference as to your suitability for the course. One should be a current or previous employer, or teacher/tutor. One could be your acupuncture practitioner if you have one.

Name / In what capacity do they know you? / Contact email (or telephone if no email)

Ethnicity

We would be grateful if you could complete the following. Please note this is for monitoring purposes only and will not be used in consideration of your application. We welcome diversity in our student population, and actively oppose discrimination on any grounds.

Which of the following most closely describes your ethnicity? Answer ‘yes’, and supply more detail if you feel comfortable doing so:

White British
Black or Black British
Asian or Asian British
East Asian or East Asian British
White – any other
Mixed race
Other ethnic group

Thank you for your application. We look forward to considering it. Please note checklist of documents to bring for interview below.

I declare that all information given in this application is true and accurate and agree to undertake a Disclosure check by the Disclosure and Barring Service (formally CRB) if deemed necessary by TAA.
Name:
(we will ask for a signed copy at interview)
Date:

CHECKLIST - We will need the following, which you can bring with you when you visit, or send electronically:

□ / Copies or originals of your most recent educational qualifications
□ / Proof of current address such as a utility bill or bank statement
□ / A clear photograph for our register and your student card (you are allowed to smile!)
□ / Proof of identity bearing your name and photograph such as a passport or driving licence (British nationals)
□ / Proof of your residency status and identity (non- British nationals)
□ / If English is not your first language, AND if your secondary education was not undertaken in English, we will require an IELTS level 6.5 certificate or the equivalent If you cannot produce this at interview, we will require it prior to commencement of the course)

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