Application Form

Postgraduate Certificate
SECTION A: All questions must be completed

A(1) Personal details

If you used a different name during previous
Name (this should be your legal name) Name (previous) study, please include it here.

Last (family) Please enter a last name Last (family) Last name

First Please enter a First name First First name

Middle names Please enter a middle names Middle names Middle names

Title (Mr/Mrs/Miss/Dr etc) Please choose a title Title (Mr/Mrs/Miss/Dr etc) Please choose a title

Date of Birth Nationality and residence

Country of permanent Do you require a visa to study in the
D D M M Y Y Y Y Country of permanent residence
residence UK?
DD MM YYYY Country of birth Country of birth ○ Yes ○ No
Sex Nationality Nationality Current UK visa status,if applicable:

○ Male ○ Female Any second nationality Any second nationality Current UK visa status

If you have a CRS ID (student identifier made up of your initials

and several numbers, e.g. jb101, please enter it here:

A(2) Contact Information

Mailing Address Home (permanent) Address (if different)
Number/street Please enter a number / street Number/street

Town or city Please enter a town or city Town or city

County/province/state Please enter a state County/province/state

Postal code

Country Please enter a Country Country

Telephone

This address is valid until: I have lived at this address since:

D D M M Y Y Y Y D D M M Y Y Y Y
Email Address Please write very clearly, we will use email to communicate
Please enter a Email Address with you during the application process.

A(3) Programme of Study

Details of your programme of study. Consult the appropriate entry on the Institute of Continuing Education’s website before
completing the fields in this section.

Course code Programme of study or research area Department Final Award Duration

Course code Programme of study or research area Department Final Award Duration
 A(4) Current Study

Tick one: ○ I am currently studying, as follows: ○ I am not currently studying – go to A (5)

Name of University Subject Date to be Expected

Degree Date started
(include country) (include Faculty / Department) obtained Grade

Name of University Subject Degree Date started Date to be Expected

obtained Grade

A(5): Previous degree-level study (most recent first).

Please supply copies of relevant certificates with this application

Name of University Subject Date

Degree Date started Grade
(include country) (include Faculty / Department) obtained

Name of University Subject Degree Date started Date to be Expected

obtained Grade

A(6) Qualifications
I confirm that I am a post-foundation-year:
Yes ☐
Doctor who has a role in training and appraising healthcare professionals
Yes ☐
Nurse who has a role in training and appraising healthcare professionals
Yes ☐
Physiotherapist who has a role in training and appraising healthcare professionals Yes ☐
Dental surgeon who has a role in training and appraising healthcare professionals Yes ☐
Other healthcare professional who has a role in training and appraising healthcare professionals
please specify below: please specify below

I confirm that I am:

Teaching in primary care Yes ☐
Teaching in secondary care Yes ☐
Teaching in tertiary care Yes ☐
Teaching/supervising mainly preclinical settings Yes ☐

Teaching mainly undergraduates Yes ☐

Yes ☐
Teaching mainly postgraduates
Yes ☐
Mixture of undergraduate and postgraduates
Yes ☐
I understand that I may be required to provide evidence of my eligibility for the course

A(7) English Language Proficiency.

Applicants to the programme must be holders of the following and be able to provide evidence of this

All teaching and assessment on this course is in English. To participate fully, you will need near-native fluency in both spoken and
written English. We ask for recent certification as part of the admissions process.

Is English your first language? ○ Yes ○ No

If English is not your first language, have you taken an English language proficiency test in the last two years?

☐ Yes IELTS Please enter your TRF number Please enter your TRF number

☐ Yes TOEFL Please enter your registration number Please enter your registration number

☐ Yes CAE or CPE Please enter your candidate number Please enter your candidate number

and your secret number Please enter your secret number

☐ No current language proficiency test. I agree to send my English proficiency test results or reference details to the Institute. We
cannot offer you a place on a course until satisfactory evidence of your language proficiency has been received.
A(8) If you have made other applications to Institute of Continuing Education this year, give details here

Degree Programme of study/research Department

A(9) If you have made applications to other institutions this year, give details here

Degree Programme of study/research Institution Department Country

A(10) Employment History

From To Post Held Name and Address of Employer

Are you currently employed? ○ Yes ○ No

A(11) Reason for applying for the course (please continue on a separate sheet if necessary)

A(12) Names and addresses of your academic referees.

It is your responsibility to ensure that academic references are submitted, your referees will not be contacted on your behalf. If you
are unable to supply these with the completed application from any place offered will be conditional upon safe receipt and approval
of the references as specified. References must be supplied on original letter headed paper and should also be signed. We cannot
accept electronic or scanned copies of documents or scanned signatures.

First referee Second referee

Name Enter a name of your academic referees Enter a name of your academic referees

Title Enter a title of your academic referees Enter a title of your academic referees

Address Please enter a state Please enter a state

Town or city Please enter a town or city Please enter a town or city

County/State or Province Please enter a State Please enter a State

Country Please enter a Country Please enter a Country

Postal Code

Email Please enter a Email Please enter a Email

 SECTION B

B(1) Next of kin

Name Enter a name

Address Please enter a state

Town or city Please enter a town or city

County, province or state Please enter a State

Post code

Telephone

B(2) How did you hear about postgraduate programmes at Institute of Continuing Education?
e.g. Prospectus, Internet, British Council, Careers Service etc (please specify)

B(3) Declaration and Data Protection

This document forms the legal basis of your application to Institute of Continuing Education. We reserve the right to refuse
admission in the event of any misrepresentation by you. Submission of an application does not imply an offer of admission. Read
the following statement carefully before you sign your application. We cannot accept your application without your signature and
the date below.

1. DATA PROTECTION ACT (1998): I agree to the Institute of Continuing Education processing personal data contained in my
application papers whether provided in confidence or not by other individuals or institutions, in support of my
application, as part of the admissions, registration and funding processes. I recognise that some of the information
received by the Institute of Continuing Education will have been provided confidentially. I also accept that, should I
be made an offer of a place and subsequently register as a student of the University, this information will be
retained during and following my studies for administering my progress and for the provision of statistical returns. I
understand that this information may also be used for the purposes of staff training.
2. I certify that all the information given in this application is complete and accurate, and I understand that if I have given false
or misleading information the Institute of Continuing Education will not admit me as a student, and may take legal action
against me.
3. I certify that I am the original and sole author of all work submitted as part of this application, except where
clearly indicated otherwise.
4. I understand that if my application is unsuccessful, the papers relating to it will be destroyed, and cannot be returned.

NAME (PRINT) SIGNATURE D D M M Y Y Y Y

 Personal Data Sheet (Part 1)

The Personal Data Sheet (Part 1) is circulated along with the rest of your application, but information on this sheet will not be
considered when making the academic decision on whether to make an offer of admission. The sheet is circulated because if
you do declare a disability below, it may be helpful for us to know this in the event that we wish to organise an interview, so that
any relevant adjustments can be made. See the Institute of Continuing Education’s website for further information about support
for disabled students.

Name Please choose a title

Last (family) First and middle
(legal)
Last (family) First and middle Title (Mr/Mrs/Miss/Dr etc)

Support needs relating to disability or chronic illness

Please tick the appropriate box below. If you do not have a disability, special needs or a medical condition, use
code 00 (‘I have no disability’). If you do not wish to provide any information in this section, use code 97
(‘Information refused’).
Under the Equality Act 2010, a disability is any physical or mental impairment which has a substantial and long
term adverse effect on an individual’s ability to carry out normal day to day activities. We invite disclosure from
anyone who feels they may have a disability or other condition which is likely to require additional support during
their time at the Institute of Continuing Education.
By completing this section you may be put in contact with the Institute’s Disability Adviser to establish what support,
if any, is required to enable you to study effectively.

☐ I have no disability (00) ☐ I have a long standing illness or ☐ I am blind or have a serious visual
health condition such as cancer, impairment uncorrected by glasses
HIV, diabetes, chronic heart (58)
disease, or epilepsy (54)

☐ I have two or more impairments ☐ I have a mental health condition ☐ I have a disability, impairment or
and/or disabling medical conditions (e.g. medical condition not listed above
(08) depression/schizophrenia/anxiety (96)
disorder) (55)

☐ I have a Specific Learning Difficulty ☐ I have a physical impairment or ☐ Information refused (97)
(e.g. Dyslexia/Dyspraxia/AD(H)D mobility issues (e.g. difficulty using
(51) arms/using a wheelchair or
crutches) (56)

☐ I have a social/communication ☐ I am deaf or have a serious hearing

impairment such as Asperger’s impairment (57)
syndrome/other autistic spectrum
disorder (53)
 Personal Data Sheet (Part 2)

Information in the Personal Data Sheet (Part 2) is retained by the University for statistical purposes only.
This section of the Personal Data Sheet is not circulated with your application.
Name Please choose a title
Last (family) First and middle
(legal)
Last (family) First and middle Title (Mr/Mrs/Miss/Dr etc)

(1) Ethnic Origin

Please tick the appropriate box to indicate your background. If you do not wish to provide information in this
section, tick the ‘Information refused’ box.

☐ White (10)
☐ Gypsy or Traveller(13)
☐ Black or Black British – Caribbean (21)
☐ Black or Black British – African (22)
☐ Other Black background (29)
☐ Asian or Asian British – Indian (31)
☐ Asian or Asian British – Pakistani (32)
☐ Asian or Asian British – Bangladeshi (33)
☐ Chinese (34)
☐ Other Asian background (39)
☐ Mixed-White and Black Caribbean (41)
☐ Mixed-White and Black African (42)
☐ Mixed-White and Asian (43)
☐ Arab (50)
☐ Other Mixed background (49)
☐ Other Ethnic background (80)
☐ Information refused (98)

SIGNATURE D D M M Y Y Y Y