APPLICATION FORM

Title
(Mr/Mrs/Miss/Ms etc) / Date of Birth
First Name / Gender
Surname
Home Address / Work Address
Postcode / Post code
Home Number / Work Number
Mobile Number
Preferred email
Manager’s name
and Telephone number

Please provide the full address of your current/most recent employer, including departmental/directorate details.

Directorate/Departmental:
Organisation Name:
Organisation Address
Job Title
Employee Payroll Number:
From / To:
Work email:

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Please provide details of work experience and employment within the last five years that is applicable for this course. Please continue on a separate sheet if necessary.

Job title / Name of Organisation / From (mm/yyyy) / To (mm/yyyy) / Duties

Please provide details of all academic and/ or professional qualifications (e.g. Msc, physiotherapy, workshops, DipHE etc. The list should also include any continuing professional development courses you have taken. If you have not yet completed the qualification, provide results achieved so far and/or expected.

Institution / Qualifications /Course title/
Professional training / From
(mm/yyyy) / To
(mm/yyyy) / Grade/Marks

In no more than 500 words please state the reasons why you wish to enrol for this course and how this relates to your career plans. Continue on a separate sheet if required.

Please disclose any disabilities, medical condition and dietary requirements which could disadvantage your ability to study with us. All offers are made on academic grounds only and the information you submit will be used to help us to provide appropriate support. (Examples: hearing impairment, lactose intolerance, mobility issues etc.)

To the best of my knowledge, the information on this application is accurate and complete. (Please note that the Hospital Trust reserves the right to refuse admission or to terminate a student’s attendance should it be discovered that he/she has made a false statement or has omitted significant information. If you are offered a place, you will be required to provide evidence of your qualifications.)
Data Protection Act 1998: I agree to UCL Hospital Foundation Trust processing personal data contained on this form, or other data which the Hospital may obtain from me or other people or organisations while I am applying for admission. I agree to the processing and disclosure of such data for any purpose connected with my studies, or my health and safety while on the Hospital’s premises or for any other legitimate purpose.
Applicant’s name (Print and signed) / Date
Manager’s Name (Print and signed) / Date

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