Highest Academic & Professional Qualification on Entry

Application forPG Certificate / PG Diploma / MA Education
I INTEND TO START my studies in: / Month / Year
WITH (please tick) / Independent Study Module (ISM)☒ / Taught Module☐ / Dissertation☐
Personal Details (please TAB between sections)
Surname: / Forename(s):
Title: / Previous Surname/ Maidenname
/ / Date of birth (dd/mm/yyyy)
Home address: / Country of Domicile:
Nationality:
Town/County: / Email:
Postcode: / Telephone:
Current Employment
Name of Employer:
Contact details of Employer:Telephone: E-mail:
Address:
Town/County: / Postcode:
Title of post held / Phase:(ie Early Years/Primary/Secondary/Special/PRU/Secure Unit/ Other)
Do you hold Qualified
Teacher Status (QTS)? / / / If YES please put a * next to the award in the entry below that gave you QTS and enter your Teacher Reference Number
Number of years teaching experience / Teacher Reference No / /
Qualifications gained after leaving school
Please provide a copy of your highest qualification certificate to date
Title / Awarding Institution or Organisation / Dates
Professional Experience
Please include main teaching and non-teaching posts and in the first column any specialism and posts of responsibility
Post / Employers Name and Address / Dates
At this stage I am interested in undertaking modules in the following area(s):
Early Years / ☐ / Further & Adult Education / ☐ / Inclusive Education and Special Educational Needs / ☐
Leading Learning / ☐ / Comparative Education / ☐ / Professional Practice Learning / ☐
Professional Development / ☐ / Mathematics Education / ☐ / Teaching and Learning / ☐
Computer Education / ☐ / Secondary Education / ☐ / Modern Foreign Languages / ☒
At this stage do you intend to undertake(please tick box)
Postgraduate CERTIFICATE / ☐ / Postgraduate DIPLOMA / ☐ / MASTER OF ARTS : EDUCATION / ☐
------
English Language Requirements
Is English your first language? / Yes ☐ / No ☐
Please list any formal English qualifications (IELTS, TOEFL etc) including examining body, score and date taken:
and include copies of test certificates with this application.
______
Criminal Convictions
Do you have a criminal conviction for offences of a violent or sexual nature against the person, and/or a conviction involving commercial drug dealing or trafficking?

Convictions that are spent (Rehabilitation of Offenders Act 1974) are not considered to be relevant.
------
Personal Statement giving your reasons for wishing to join the IMP.
This information helps us to help you so please elaborate on (i) personal interests in particular subjects and issues;
(ii) professional development in key areas; (iii) the challenge of a new post; (iv) particular needs of your school
Sponsorship Details (if applicable)
Sponsor Name / Full address for invoice (including Self):
For the attention of:
E-mail: / Telephone:
Please enter details of any sponsors to be invoiced for your tuition fees. If left blank we will presume you are self-funding and invoice you for any fees due.
Emergency Contact Details
Contact Name / Address & Telephone Number (if different from Home Address)
Relationship
Ethnicity & Disability Information(please tick appropriate number for each section)
As a requirement of the Race Relations Act (2000) we need to know your ethnic origin for the purpose of monitoring equality of opportunity to all ethnic groups, highlighting possible inequalities and enabling the implementation of action to remove any barriers and discrimination. This information will be treated as STRICTLY CONFIDENTIAL for Disability Assist Services or Equal Opportunities purposes and will not be taken into consideration for your application.
ETHNIC ORIGIN
☐11 White – British
☐12 White – Irish
☐19 Other White Background
☐21 Black or Black British Caribbean
☐22 Black or Black African
☐29 Other Black Background
☐31 Asian or Asian British – Indian
☐32 Asian or Asian British – Pakistani
☐33 Asian or Asian British - Bangladeshi / ☐34 Chinese or other ethnicbackground – Chinese
☐39 Other Asian Background
☐41 Mixed – White and Black Caribbean
☐42 Mixed – White and Black African
☐43 Mixed – White and Asian
☐49 Other Mixed Background
☐80 Other Ethnic Background
☐90 Not Known
☐98 Information Refused / DISABILITY
☐00 No Known Disability
☐02 Blind / partially sighted
☐03 Deaf / hearing impairment
☐04 Wheelchair user /mobility difficulties
☐05 Personal care support
☐06 Mental health difficulties
☐07 Unseen disability eg diabetes, epilepsy, asthma
☐08 Multiple disabilities
☐10 Autistic Spectrum Disorder
☐11 A specific learning difficulty eg dyslexia
☐96 A disability not listed above
☐97 Information refused

Data Protection Act 1998

The information which you give on your application form will be used for the following purposes only: A) to enable your application to the University to be considered; B) To enable the University to compile statistics, or to assist other organisations or individual research workers to do so, provided that no statistical information which would identify you as a person will be published; C) To enable the University to initiate your student record.

Expectations and Entitlement

By registering on the University of Plymouth International Masters Programme (IMP) you are agreeing to undertake professional development at Masters level. You are entitled to appropriate tutor support, full access to University of Plymouth libraries and electronic library resources and online research support materials (RESINED) – further details are available at

Additional Information

Student Declaration: I certify that the information given on this form is correct to the best of my knowledge. I have received a Notice on Data Protection which explains the use made by the University of student personal data. I agree to abide by the Institution’s Regulations and Code of Conduct and I understand that I am assigning certain Intellectual Property Rights (IPR) to the University. The Regulations, Code of Conduct and details of IPR assignment appear in the Student Handbook available at
Signature ...... Date (dd/mm/yyyy):
Please note that on submitting this form by email you have accepted these terms and agree to this declaration.

Signature of Programme Leader

Signature ...... Date (dd/mm/yyyy):
Fee Details (Office Use Only)
Fee Region
Debtor Flag
Total Fee for Academic Year:
Who will pay the fees? (circle as appropriate) / If no fee payable please give reason:
(Paid in previous year/Board Purposes Only/Other)
Self / SLC / Sponsor / More than one
Please provide details of amounts to be paid: / Fee Reduction Applicable? Yes / No
Payer / Amount / Payer / Amount / Reason for Reduction:
Amount of Reduction (£/%):

PLEASE COMPLETE THIS APPLICATION FORM AND RETURN BY EMAIL TO Dec 14