Part-Time Application/Registration Form 2016-2017
Programme Name / Certificate in 3D Printing and Embedded Systems
Programme Code LC_E3DEP_RTH
Programme Location: LIT Thurles and WeCreate Workspace and Fab Lab, North Tipperary Green Enterprise Park, Cloughjordan, Co. Tipperary

Have you previously studied at LIT, LIT Tipperary or Tipperary Institute?

No ð Yes ð
If yes, which programme did you study?
Student ID No. (if previous TI student) / / Surname
Prefix /

Mr ð Mrs ð Ms ð Miss ð

/ First Name /
Permanent Home
Address / Address for Correspondence
(If different from permanent address)

E-Mail:

/

Phone No

/ /

Mobile Phone No

/

Next of Kin Name

/

Date of Birth

/ / / .

Relationship

/

PPS

Next of Kin Address

(If different from Permanent Address)

/

Gender

/ Male ð / Female ð

Nation of Birth

Nation of Citizenship

Next of Kin Phone

/

Mother Tongue

Bank Details Bank details are required for refund purposes.

A/C No

/ Sort Code:
Bank Name
Bank Address
Data Protection
LIT fully respects your right to privacy. Any personal information you volunteer to LIT will be treated with the highest standards of security and confidentiality, strictly in accordance with the Data Protection Act, 1988 & 2003.
Student Declaration (must be signed by all applicants). Please see www.lit.ie/foi/Section16 for the Institute’s Rules and Regulations. I confirm that the information on this form is correct to the best of my knowledge. I agree to abide by the rules and regulations of the Institute.
Signature: ______Date: ______
Completed Applications to: /
Administrator, Certificate 3D Printing & Embedded Systems,
Department of Flexible Learning,
Limerick Institute of Technology – Thurles Campus
Nenagh Road, Thurles, Co. Tipperary
Office Use only
ID
Closing date for receipt of applications is Monday 12th September 2016

Please note that it is essential that this application form is completed in full, in order for us to evaluate if entry requirements have been met and for the purpose of scoring your application.

EDUCATIONAL HISTORY
Secondary School Education
Name of School
Address
Dates / From: / To:
Did you complete the Junior Certificate / Intermediate Certificate? Yes No
Did you complete the Leaving Certificate? Yes No
*Copies of all Certificates / Results must be attached
*Incomplete applications will not be considered
FETAC Qualification
Do you have a full FETAC Award? Yes No
Name of School / College:
Level of Award: /
*Copies of all Certificates / Results must be attached
*Incomplete applications will not be considered
Third Level qualification?
Did you ever go to a Third Level College? Yes No
Name of College:
Title of Programme:
Did you complete the Programme? Yes No
Date of Entry: / Date Conferred: / Award:
*Copies of all Certificates / Results must be attached
*Incomplete applications will not be considered
Please list other educational qualifications/training programmes you may have attended:
Continue on an additional sheet if required
*Copies of all Certificates / Results must be attached
*Incomplete applications will not be considered
EMPLOYMENT HISTORYProvide details of relevant work experience (if any):
Current Occupation (or last occupation if currently unemployed):
Employer’s Details (if appropriate) – do state if you are self-employed:
Name: / Nature of Business:
Address
Self Employed Yes / No
Please provide a brief description of your duties and responsibilities:
Please describe any relevant experience you may have in digital manufacturing:
Additional Information
Please indicate your reason(s) for applying to do this course:
What do you want to achieve from this course?
INFORMATION TECHNOLOGY SKILLS – all applicants must complete this section
Please provide an indication of your current computer literacy
Do you have experience of using computer applications? Yes No
Please indicate the level of your Computing Skills: / No Experience / Average Skills / Excellent Skills
Word processing (MS Word)
Spreadsheets (Ms Excel)
Presentation Software (MS PowerPoint)
Databases (MS Access)
Internet Browsing (Internet Explorer)
Have you access to a computer with internet connection? / Yes / No
Where did you hear of this programme?
LIT Website: [ ] Mailshot: [ ] Email: [ ] LIT Information Evening: [ ]
Radio: [ ] Local Press: [ ] Till Receipts: [ ] Word of Mouth: [ ]
Road Signs: [ ] Event: [ ] (specify which): ______

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