APPLICATION FOR ADMISSIONS TO AN UNDERGRADUATE (P/T) OR POSTGRADUATE PROGRAMME

Please use BLOCK CAPITALS throughout

PERSONAL DETAILS

Title Dr/Mr/Mrs/Miss/Ms

Surname/Family name

Forenames

Correspondence Address
        
        
        
        

Post Code

Tel No: (Please include international code if applicable)

Fax No:

Email address:

Home Address (if different from above) 

         
         
         
         

Post Code 

Tel No: (Please include international code if applicable)

Fax No: 

APPLICATION NO:

APPLICATION FOR ADMISSION TO:

(Please tick as appropriate)

           POSTGRADUATE PROGRAMME

           UNDERGRADUATE PROGRAMME

MODE OF STUDY:

         FULL TIME

         PART-TIME

         DISTANCE / OPEN LEARNING

Note: Application to Undergraduate Full-Time Courses should be through UCAS.

Applications should be made directly to the University for part-time courses, including degree and professional programmes of study. Applications are available from the University Admissions Office or Online. Please do not use this form to apply for online programmes; all applications for online programmes should be completed online.

                                                                                                  ACCREDITATION OF PRIOR LEARNING   (APL)

    DO YOU WISH TO APPLY FOR APL?

                                                            (tick box if YES)       

Date of Birth : Day   Month  Year

Nationality:

Area of permanent residence:

Country of birth:

Do you have any unspent criminal convictions, excluding motoring offences?                    Yes      No

If yes, please send details on a separate sheet of paper.

Do you have any disabilities or special needs?
Yes    No

Please give brief details:

 

1.             FIRST PROGRAMME CHOICE:

                a)             i)              Title of programme:

                                 ii)             Intended Award eg BA, PG Diploma etc:

                b)             Intended start date:

                c)             Is this application for first  year entry of course? Yes No

                                 If NO please specify year:

                COMBINED SUBJECT PROGRAMMES  ONLY  (Two/three subjects must be chosen for Stage 1 entry)

                d)             i)     Subjects to be studied:

                                 ii)   Alternative choice of subjects:

                FOR PG CAMS ONLY

                                 Name of Programme Leader (see prospectus):

2.             ALTERNATIVE PROGRAMME CHOICE  (if appropriate):

                Subject choice(if appropriate):

3.             ACADEMIC/PROFESSIONAL/VOCATIONAL QUALIFICATIONS

                a)             All examinations or assessments for which results are known

                                 (Applicants with no formal qualifications, please complete Sections 4 and 5)

Award Date

Mth      Yr

Name of Establishment

Awarding Body

Subject/unit/module/

component

Level

Result/Grade/Score or Band
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             

3.             b)             Examinations or assessments to be completed, or results pending

Exam Date

Mth      Yr

Name of Establishment

Awarding Body

Subject/unit/modular/

component

Level

Title of examination
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             

                Is English your first language? Yes    No

                If No state English language qualification eg. TOEFL/IELTS or equivalent: 

3.             c)             Please detail membership of any Professional Bodies eg. Institute of Personnel Management (IPM) , Chartered                   Institute of Management Accountants (CIMA) etc.

 
 
 
 
 

4.             WORK HISTORY - State in date order (most  recent first) details of your work history, paid or unpaid, which you believe relevant to             your application.

Position

Dates

From

To

Brief description of responsibilities
       

If you are currently in employment and applying for a  course please supply name and address of sponsor if applicable.

Name                                                                                                         Position

Address

 

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

 

(A continuation sheet can be used)

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  ..................................................................................................

NOTE:    Applicants should now forward this completed form, including transcripts of completed courses to their Referee for completion (if applicable), with a stamped envelope addressed to the Admissions Officer, University of Derby, Kedleston Road, Derby  DE22 1GB.

6.             REFERENCE  (This is required for all courses, unless otherwise stipulated.  For those who have been in continuous education this would normally come from your FE/HE  course tutor etc.)

Name of Referee                                                                                                                     Telephone No:

Position/Occupation                                                                                                               

Name and address of School/FE/HE Institution/Employer
 
 

Should this reference be treated as confidential?     Yes       No   

SIGNATURE   ...........................................................................................                              DATE   ....................................................................

All application forms must now be forwarded to the
Admissions Officer, University of Derby, Kedleston Road, Derby DE22 1GB

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