B065-0001-7 App Form CPD:B065-0001-5 App Form 1/10/07 11:12 Page 1
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Application Form Application Ref No:
(For Institution use only)
Solely for applications not handled by the Universities and Colleges
Admissions Service (UCAS) or other clearing houses.
Please read the accompanying Notes for Guidance before completing this form.
Please complete all sections of this form and return to:
Recruitment and Admissions, University of Bolton, Deane Road, Bolton BL3 5AB
1 Title/Name/Address Title
Surname/
Family Name
First/given
name(s)
Postal Address Home Address
line 1 (if different) line 1
Address line 2 Address line 2
Address line 3 Address line 3
Address line 4 Address line 4
Postcode Postcode
(UK only) (UK only)
Mobile Tel: Home contact Tel:
Number number
(including STD/
email area code) Fax:
2 Further Details
Your age on 30 September in year of entry Area of permanent residence
Years Months Date of first entry to live in UK
Male (M)/ Country of birth
Female (F)
Nationality
Date of birth
Additional
Learning Ethnic Origin Code Not used for selection purposes. Residential Category
Support Code (UK applicants only) Please refer to guidance notes for appropriate codes. (see notes)
(see notes)
3 Details of course(s) for which you wish to apply
Month and year in which you wish to start Name of Partner College:
Course Title Preliminary choice of main Mode of study: full time/ Year Stage: ie
subjects/options (if applicable) sandwich/part-time/ of Year 1
other Please specify entry Year 2
Please indicate how you heard of these courses
Have you previously studied at The University of Bolton? Yes No If yes, please complete the following as fully as possible.
Dates Attended Course Studied Student Number (if known)
From To
From To
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4 Name and address of the two most recent educational establishments attended,
within the last ten years only. From To FT or PT
Month Year Month Year
5 Formal qualifications Summary
Scottish Highers HNC / HND
of qualifications held
Please tick Irish Highers Foundation Degree
Welsh Bacc. First Degree
I.B Postgraduate Cert. / Dip
No formal qualifications
Accredited Access Course Applicants for Post Compulsory If you have completed a Modern
Education Courses MUST state: Apprenticeship, state which skill was covered:
NVQ Level 2
NVQ Level 3
GCSE Maths grade C & above Other - please specify
NVQ Level 4 & above
GCSE / GCE / CSE GCSE English grade C & above
AS / A level / AVCE
5a Examinations/Assessments: Applicants should list all subjects taken, whatever the result, in chronological order. If you are awaiting the result of
any examination recently taken write PENDING in the result column. Qualifications awarded by BTEC or SCOTVEC - please attach transcript of
all results if known. Where examinations are still to be taken, please list all modules with value and level of each. Continue on a separate sheet if
necessary.
Applicants who wish to be considered for accreditation of prior learning please complete this section in full.
Level, eg GCSE, Subject / Unit / Module / Component Date Place of study Results CATS
A/AS/VCE, HND, Month Year (grades or points (if
degree or professional bands) applicable)
qualifications
6 WORK EXPERIENCE (Please consult guidance notes) From To PT/
Job title & nature of work
Names and addresses of recent employers. Continue on a separate sheet if necessary. Month Year Month Year FT
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7 ADDITIONAL
LEARNING SUPPORT
required as a
consequence of any
condition stated in
section 2.
Applicants for Health/Nursing related courses please enter NMC PIN number:
8 PERSONAL STATEMENT Health/Nursing CPD applicants see guidance booklet
9 CRIMINAL CONVICTIONS: Do you have any criminal convictions? See guidance notes YES NO
10 DECLARATION: I confirm that the information given on this form is true, complete and accurate and no information requested or other material information has been omitted. I
undertake to be bound by the University’s terms and conditions and I give my consent to the processing of my data by the University. I accept that, if I do not fully comply with
these requirements The University of Bolton shall have the right to cancel my application and I shall have no claim against The University of Bolton in relation thereto.
Please sign and return this form to:
Recruitment and Admissions, University of Bolton, Deane Road, Bolton BL3 5AB.
Applicant’s Signature..................................................................................................................................................... Date........................................................................
REMEMBER TO KEEP A PHOTOCOPY.
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11 REFERENCE
Applicants for Teaching in Post Compulsory Education, MEd and BA Education please ask one of your referees, detailed in section 12, to supply a
reference in this section of the form, and forward the completed application to us.
Applicants for Health and Nursing CPD courses do not complete this section, but move to section 12.
Applicants who are applying to study with one of our partner colleges must hand the completed form to the Centre Leader who is requested to
confirm the applicants acceptance by signing below.
Name of referee / Centre Leader
Post / Occupation / Relationship
Name and address of school / college / organisation
Tel: Fax:
email:
Name of applicant (block capitals or type)
Referee’s / Centre Leader’s Signature:
Date:
12 Only to be completed by applicants for teaching in Post Compulsory Education, MEd and BA Education courses, Nursing courses.
(Please give as referees two persons who are able to speak of your academic work and experience in industry, commerce or public services)
Health/Nursing CPD applicants see guidance booklet
1. 2.
email Address email Address
Tel No. Fax No. Tel No. Fax No.
SEE GUIDANCE NOTES
