APPLICATION FORM

FOR UNIVERSITY USE ONLY

SITS Applicant No. SITS AoS Code:
Please return to:
Birmingham City University,
Decision Interview Date: Admissions,
Reject Conditions of offer: University House,
15 Bartholomew Row,
Offer Birmingham,
B5 JU
Signed: (Admissions Tutor/Course Director)

This form requests a significant amount of personal information. This is required so that we can decide on your suitability for the course you are
applying for. The information you provide will be used for this purpose and monitoring of equal opportunities only. It will be treated in confidence and
will only be seen by those whose jobs require them to do so.

Please complete in BLOCK CAPITALS

1. Course Details

Course Title:

Proposed start date: Full-time Part-time

Proposed Year/Level of Entry: Year 1 Year 2 Year 3

2. Personal Details
Day Month Year

Title: Mr/Ms/Miss/Mrs etc. Gender: Male Female Other Date of birth:

First name(s):

Maiden or any other name(s) that you have been known by:

Surname/family name:

Permanent address:

Country: Postcode:

Correspondence address (if different):

Country: Postcode:

Daytime telephone: Evening telephone (if different): Mobile:

Email address: Nationality:

If not born in the UK please state date of arrival to UK: Area of permanent residence:

If you are a member of a Professional Body, please give its name and your Registration Number:

Have you ever studied in the UK before? (If yes, please include a copy of all visas) Yes No

What level was your previous study in the UK (please tick all that apply)? Foundation Degree Master’s

Have you ever studied at Birmingham City University before? Yes No

3. Academic and Professional Qualifications
Please enter details of the highest level of qualification you currently hold.

Qualifications, eg: GCSE, HND, Degree, Subject/unit From To Place of study Results CATS points and
Access, NVQ, Postgraduate, Master’s, month/year month/year (grade level (if applicable)
Professional or band)

Now please list all other qualifications taken, whatever the result, in reverse chronological order ie: latest first. If you are awaiting the result of
any examination please indicate the date in the results column. Please continue on a separate sheet if necessary.

Qualifications, eg: GCSE, HND, Degree, Subject/unit From To Place of study Results CATS points and
Access, NVQ, Postgraduate, Master’s, month/year month/year (grade level (if applicable)
Professional or band)

If you have a 10 digit Unique Learner Number (ULN), please enter it in the box provided.

If you are an overseas student please include your IELTS/TOEFL results below:

IELTS overall band score: TOEFL internet-based test score:

The University may also accept other approved qualifications equivalent to the IELTS/TOEFL test scores.
Please list these above or on a separate sheet if necessary.

4. Employment and Work Experience

Please give details of work experience, training and employment in reverse chronological order.

Nature of work/training Name of organisation Full-time or From month/ To month/

part-time year year
5. International Students
Did you use an agent to help you find this course? Yes No

Agent’s name: Agent’s email:

6. Referee(s)
Name and address of Referee(s):

Name: Name:

Address: Address:

Postcode: Postcode:

Telephone: Telephone:

Fax: Fax:

Email: Email:

7. Supporting Statement
Please enter here any further information in support of your application, for example, reasons for choosing the course, your professional career to
date (if relevant) and your current career goals. Please continue on a separate page if required.
8. Disabilities
Do you have any special needs? (please tick). The information you provide will be treated confidentially and will not affect judgements concerning your
academic suitability for a course.

A No disability.

B You have a social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder.

C You are blind or have a serious visual impairment uncorrected by glasses.

D You are deaf or have a serious hearing impairment.

E You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy.

F You have a mental health condition, such as depression, schizophrenia or anxiety disorder.

G You have a specific learning difficulty such as dyslexia, dyspraxia or AD(H)D.

H You have a physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches.

I You have a disability, impairment or medical condition that is not listed above.

J You have two or more impairments and/or disabling medical conditions.

9. Declaration
I confirm that the information given on this form is true, complete and accurate and that none of the information requested or other material
information has been omitted. I accept that if it is discovered that I have supplied false, inaccurate or misleading information, Birmingham City
University reserves the right to cancel my application, withdraw its offer of a place or terminate attendance at the University and I shall have no
claim against Birmingham City University in relation thereto.

Applicant’s Applicant’s
Date:
name: signature:

PLEASE INDICATE HOW YOU HEARD ABOUT THE COURSE (please tick relevant boxes):

Advertisement Careers service Alumni Colleague/friend

Education fair Employer Current student Internet (general)

Previous student Professional association Direct mail Personal enquiry to Birmingham City University

Birmingham City University Course Enquiries Team Birmingham City University website

Other (please specify):

REPORT ON APPLICANT

Referees should note that the contents of this report may be shown to the applicant on request.
To the Candidate:
Please fill in your name and course details below, detach and forward this part of the form to your referee for completion.

Applicant’s name: Date of birth:

Course applied for:

To the Referee:
I am applying for admission to the above course at Birmingham City University. The University would appreciate your personal impressions of my
intellectual ability and professional skills.

Please comment on my character, quality of previous work, personal strengths and weaknesses, and potential.
(Please use a separate sheet if you prefer).

Signed (applicant): Date:

Name and position:

Institution:

Address:

Country: Postcode:

Telephone: Fax:

Email:

How long have you known the applicant and in what capacity?

Please comment on the applicant’s suitability for the course with particular reference to his/her strengths.
How would you rate the applicant in relation to the following? (please tick appropriate boxes)

Below Unable
Excellent Very good Average average to comment

Motivation

Ambition and drive

Originality and creativity

Problem solving skills

Decision making skills

Time management skills

Oral communication skills

Written communication skills

Numeracy

Please add any other comments you feel would be helpful in supporting their application to the University:

Name of referee: Signature of referee:

Date:

Thank you for completing this form. Now please return it to:
Birmingham City University,
Admissions,
University House,
15 Bartholomew Row,
Birmingham,
B5 JU