Application Form for Supported Online Study

(Fill in BLOCK CAPITALS)

AGENT DETAILS

Partner Name: / Domain Academy (Domain Group) / Partner ID: / 100321619

PERSONAL DETAILS

Title:
Last / Family name:
First name/s:
Date of Birth (dd/mm/yyyy):
Correspondence Address: / (Country)
Post code:
Telephone Number:
Mobile Number:
Email Address:
Nationality:
Area of permanent residence:
Country of Birth:
If you were born outside the UK, but now live in the UK, please give date when you began living here permanently (dd/mm/yyyy):
Do you have a disability? / YES NO
(if yes, please give brief details):
Do you have any unspent criminal convictions? / YES NO

PROGRAMME DETAILS

Name of programme:
When would you like to start? / Year:
Month: / SEPTEMBER JANUARY MAY

QUALIFICATIONS (Please provide details of your qualifications, including those not yet completed)

Qualification achieved / Result / grade / score / Date of awarded(dd/mm/yyyy) / Name of Awarding Body
Is English your first language? / YES NO
If NO, state English language qualification, eg: TOEFL / IELTS or equivalent:

WORK HISTORY (please write here details of your work history which you believe will help support your application.)Please list the 3 most relevant work experiences.

Company Name Address &Position/Title / Date from
(dd/mm/yyyy) / Date to
(dd/mm/yyyy) / Brief description of responsibilities

REFERENCE (this is required for all courses, unless otherwise stated)

Name of Referee:
Position/Occupation:
Telephone Number:
Email Address:
Address including postcode:

PERSONAL STATEMENT (Please write here why you want to study your chosen course)

You are invited to use this opportunity to provide information in support of your application including previous areas of study, areas of research, your reasons for applying for this programme and how you would benefit from it. You may also include non-academic experience including hobbies / interests, participation in clubs /societies, voluntary community work, parenting etc.

(Please use a continuation sheet if necessary)

I declare that, to the best of my knowledge, the information given in this form is correct. I give my consent to the processing of my data by the University of Derby.

Signature:
Date(dd/mm/yyyy):