Distance Learning Application Form
Staffordshire University Home Page
 
 

Whilst completing the form, PLEASE ENSURE THAT YOU READ THE GUIDANCE NOTES OF EACH SECTION CAREFULLY. You should also read our current literature relating to the course(s) for which you are applying in order to ensure that you are familiar with the curriculum and entry requirements.

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Please send comments and questions about this form to central-admissions@staffs.ac.uk
   
 
   
1.
Personal Details
 
 
Title: Male Female
Surname/Family Name:  Previous Surname, if changed: 
First Name(s):
Date of Birth:  /   / 
   
 
Home Address
Address (1):
Address (2):
Town/City:
County/State:
Post/Zip Code:
Country:
Tel. daytime:
Tel. evening:
Tel. mobile:
Fax number:
Email:
Email (confirm):
Correspondence Address (if different)
Address (1):
Address (2):
Town/City:
County/State:
Post/Zip Code:
Country:
Tel. daytime:
Tel. evening:
Tel. mobile:
Fax number:
Email:
Email (confirm):
   
  I am a student
   
 
   
2.
Details of the taught Postgraduate/Post-experience Course(s) to which you are applying (eg MSc/MBA/MRes)
 
  Month and year in which you wish to start:
   
 
1st Choice:
 
2nd Choice:
   
  * Subject to validation
   
 
   
3.
Where did you hear about Staffordshire University and/or our courses? Please tick as many as are applicable
   
 
School/College/University
Former Student
British Council
Web Site
Prospectus
Careers Adviser
Article/Advertisement
Other
   
 
   
4.
Fee Status
 
 
Country of Birth:  if other, please specify
 
 
Country of Nationality:  if other, please specify
 
 
Country of Domicile / Area of
Permanent Residence: 		 if other, please specify
 
   
 
   
5.
Will you, your parents or your spouse have been resident in the UK or an EU country for non-educational purposes throughout the 3 years immediately preceding admission to the University?
   
 
You: Yes No Your parents: Yes No Your spouse: Yes No
   
  If none of the above is applicable, has the Home Office granted you any of the following?
  Refugee or Asylum status in the UK Indefinite leave to remain in the UK Exceptional leave to remain in the UK
   
 
   
6.
Career History/Voluntary Work/Relevant Experience
 
  Please give details of your last two situations relating to employment, training and/or professional experience (most recent first)
   
  1.
  Date from to (mm yyyy)
 
Employer's name:
Address:
Post held: FT PT
Main functions:
Reason for leaving:
   
  2.
  Date from to (mm yyyy)
 
Employer's name:
Address:
Post held: FT PT
Main functions:
Reason for leaving:
   
 
   
7.
 Academic History/Professional History
 
  * In order for us to process your application, you must submit a copy of the transcript / certficate for any qualifications you have gained. When you submit this form you will be given details of how to do this.
   
  Please give details of the last two universities/colleges you attended (most recent first).
If you have not attended a college or university before, please click this box:
   
  1.
  Date from to (mm yyyy)
  Name of Institution
 
  Qualification(s) gained, the level, the subject, the grade and the date on which you received it, eg:
Degree, BA(Hons) Interactive Multimedia, class 2.1, July 2000 (if they were received) *
 
   
  2.
  Date from to (mm yyyy)
  Name of Institution
 
  Qualification(s) gained, the level, the subject, the grade and the date on which you received it, eg:
Degree, BA(Hons) Interactive Multimedia, class 2.1, July 2000 (if they were received) *
 
   
 
   
8.
English Language Competence
 
  * In order for us to process your application, you must submit a copy of the transcript / certficate for any qualifications you have gained. When you submit this form you will be given details of how to do this.
   
  Is English your first language? Yes No
  Was English the language of instruction for your previous qualifications? Yes No
  If 'No', please indicate if you hold any English language qualifications (eg IELTS, TOEFL .etc) including grades and dates. *
 
   
 
   
9.
Academic/Professional Interests and Purpose of Study
 
  If you wish to apply for a taught Postgraduate award please outline your reasons for wishing to undertake your chosen programme of study.
 
   
 
   
10.
Name and Address of Referees
 
  You are normally expected to provide two written academic references from people (not a relative) who have direct knowledge of your work/academic ability. It is important that you read section 10 of the guidance notes.
   
  1.
 
Name:
Address:
Tel. number:
E-mail: Fax number:
   
  2.
 
Name:
Address:
Tel. number:
E-mail: Fax number:
   
 
   
11.
Disability/Additional Needs
 
  Staffordshire University welcomes applications from students with additional support needs, and will make every effort to accommodate your requirements. Please indicate from the list below which describes your needs.
   
  Do you have a disability or aware of any associated additional support requirements in study or accommodation?
  Y N        (If yes, please give us details of your disability below, otherwise, go to section 12.)
   
  You have a specific learning difficulty (for example, dyslexia)
  You are blind or partially sighted
  You are deaf or hard of hearing
  You use a wheelchair or have mobility difficulties
  You have Autistic Spectrum Disorder or Asperger Syndrome
  You have mental health difficulties
  You have a disability that cannot be seen, for example, diabetes, epilepsy or a heart condition
  You have two or more of the above
  You have a disability, special need or medical condition that is not listed above.
(Please specify in the box provided below. Any information provided will be treated in confidence and will only be revealed to members of staff to allow effective and appropriate support to be arranged if required.)
 
   
 
   
12.
Payment of Fees - Who are you expecting to pay your fees?
 
  If other, please specify
 
  If an NHS Trust, which one?
 
   
  Are you applying for any other courses at Staffordshire University this year? Yes No (If Yes, please state which)
 
   
 
   
13.
Criminal Convictions
 
  If you have a relevant criminal conviction, please tick the box
   
 
   
14.
Declaration
 
  I confirm that, to the best of my knowledge, the information given on this form is correct and complete. (Please tick)