Application Form for Admission to a

Taught Postgraduate Programme

Please write clearly, with names and addresses in BLOCK CAPITALS

1 Programme of study:

Start date Month Year Full-time Part-time Distance-learning

2 Applicant’s details:

Title Mr Mrs Miss Ms Dr Other (please specify)

Surname Khastavan Other names

Gender (tick one) Male Female ✔ Date of birth Day Month Year

Permanent home address No. 19 the first west 18 meter, elahiye town, eslamshahr tehran iran
Postcode 3316695747
Telephone 00 98 2156832456 Mobile 00989124021996
Email

Address for correspondence (if different from above)

Postcode Agent’s reference number

To be used until Unless other instructions are given, subsequent correspondence will be sent to the permanent home address

Telephone Mobile

Email

Nationality Country of birth

Country of permanent residence

Applicants not born in the United Kingdom please state date of last entry to the UK

Day Month Year

3 Fees/sponsorship:

Who is expected to pay fees? Applicant ● Local Education Authority Research Council
Employer Sponsor/Parent/Guardian Other (please specify)

Name and address to which fee invoice is to be sent (if other than applicant)

If your attendance at the University will be conditional upon the agreement of your employer, please tick
P.T.O.
4 Education: school since the age of 11 (This section does not need completing)
Schools attended Date started Date finished Examinations taken and Grade Date
qualifications obtained

Education: since the age of 16 (Please include first degree and any postgraduate qualifications)
Institutions attended Date started Date finished Examinations taken and Grade Date
qualifications obtained

Examinations to be taken/with results Grade Date

pending (give subject and qualification)

5 Employment experience

Present position Date of appointment

Workplace address

Telephone

Name and address of employing body (if different from above)

Telephone

Details of previous posts held From To

6 References (This section does not need completing)

Name Position

Address

Telephone Email

Second referee
Name Position

Address

Telephone Email
7 Supporting statement (This section does not need completing)
Why do you wish to study this course? (Please use additional paper if necessary)

8 English language proficiency (GPhC registration is evidence of English proficiency)

What is your first language?

If your first language is not English, please give your IELTS score or

TOEFL score (if applicable)

If you have not taken an English test yet, what date do you plan to take it? Day Month

Year

What other English language qualifications do you hold?

How many years have you studied English language? Four years
Have you been taught in English in your home country? Yes No If yes, please give details

9 Disability
Please circle from the list below the statement which is most appropriate to you:
000 You do not have a disability, nor are you aware of any additional support requirements
010 You have dyslexia
020 You are blind/partially sighted
030 You are deaf/have a hearing impairment
040 You are wheelchair user/have mobility difficulties
070 You have an unseen disability (eg diabetes, epilepsy, asthma)
080 You have two or more of the above difficulties/special needs
090 You have a disability not listed above (please give details on a separate sheet)

Does your disability mean that you have additional support needs? Yes No ✔
If yes, we will contact you to determine appropriate support for you.
Tear off slip Application ref no:

Planning statistics

Ethnic origin (please note that this information WILL NOT be made available to
Admissions Tutors for selection purposes)

Complete this section only if you have shown in Section 2 of the form that your area
of permanent residence is in the UK.

Please choose your ethnic origin and write its code in the boxes.

White
British 11
Irish 12
Other white background 19

Black or black British

Caribbean 21
African 22
Other black background 29

Asian or Asian British

Indian 31
Pakistani 32
Bangladeshi 33
Chinese 34
Other Asian background 39

Mixed
White and black Caribbean 41
White and black African 42
White and Asian 43
Other mixed background 49

Other ethnic background 80

Not given (UK domicile) 90
Overseas domicile 99
11 Market research
In order to assist us to market our courses more effectively, could you please specify how you came to
hear of our course? Please tick one box.
Prospectus TV advert Careers office Careers fair Radio advert

Own initiative Press advert Other (please specify)

13 Declaration
I declare that, to the best of my knowledge, the information I have given above is correct in every detail.
If enrolled, I agree to abide by the regulations in force at the time.

Applicant’s signature Date

The completed application form should be returned to:

The Academic Registrar, De Montfort University, The Gateway, Leicester LE1 9BH

Checklist for additional information to send with your form or as soon as possible afterwards:
Supplementary Information Request form Certificates and/or transcripts of your academic qualifications
Reference Other