FOR UNIVERSITY USE ONLY

SITS Applicant No. SITS AoS Code:

Decision: Interview Date:
Reject Conditions of Offer:
Offer

Signed: (Admissions Tutor/Course Director)

Application Form Please return to:

Please complete in BLOCK CAPITAL
Birmingham City University, City North Campus, Admissions Division
Academic Registry, 4th Floor, Edge Building, Perry Barr, Birmingham B42 2SU
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.

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 Date of Birth:

First Name(s):

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

Surname/Family Name:

Permanent Address:

Country: Post Code:

Correspondence Address: (if different)

Country: Post Code:

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

E-mail 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 applies)? Foundation Degree Masters

Have you ever studied at Birmingham City University before? YES NO

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. (please tick)

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.

Have you ever been in Care? YES NO Do not want to disclose

Do any of your parents have any higher education qualifications
such as a degree, diploma or certificate of higher education? YES NO Don’t Know
 3. Academic and Professional Qualifications
Please enter details of the highest level of qualification you currently hold.
Qualifications, eg: GCSE, HND, Degree, Access, From To Results CATS points and
Subject/Unit Place of Study
NVQ, Postgraduate, Masters, Professional Year Year (grade or band) level (if applicable)

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, Access, From To Results CATS points and
Subject/Unit Place of Study
NVQ, Postgraduate, Masters, Professional Year Year (grade or band) level (if applicable)

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/Pearson Test of English results below:
IELTS overall band score TOEFL internet-based test score Pearson Test of English test score
The University may also accept other approved qualifications equivalent to the IELTS/TOEFL/PTE 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.
Full-time or From To
Nature of work/training Name of organisation
Part-time Month Year Month Year

5. Criminal Convictions
The University has a duty to ensure the safety and security I have a relevant criminal conviction that is not spent
of its students and staff. Please tick box if either of the
following statements applies to you: I am serving a prison sentence for a relevant criminal conviction

Convictions that are spent (as defined by the Rehabilitation of Offenders Act 1974) are not considered to be relevant and need not be disclosed. The definition of a
relevant conviction is one for offences against the person, whether of a violent or sexual nature, or for offences involving unlawfully supplying controlled drugs or
substances where the conviction concerns commercial drug dealing or trafficking. Such a disclosure does not automatically exclude you from the application
process but the University reserves the right to ask for further information about the conviction.
 6. Referee(s)
Name and Address of Referee(s).

Name: Name:

Address: Address:

Post Code: Post Code:

Telephone: Fax: Telephone: Fax:

E-mail: E-mail:

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. 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
Name: Signature: Date:

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)

 Equal Opportunities Monitoring

Name: Date of Birth:

THIS INFORMATION WILL NOT BE GIVEN TO ADMISSIONS TUTORS INVOLVED

IN MAKING DECISIONS ABOUT YOUR ELIGIBILITY FOR THE COURSE.

As part of its equal opportunities policy, Birmingham City University monitors applications by gender, ethnic origin and disability. Provision
of information on ethnic origin is voluntary but we hope you will agree to provide it to assist us to monitor our equal opportunities policy.

Please tick the appropriate box.

10 White
15 Gypsy or Traveller
21 Black or Black British - Caribbean
22 Black or Black British - African
29 Other Black background
31 Asian or Asian British - Indian
32 Asian or Asian British - Pakistani
33 Asian or Asian British - Bangladeshi
34 Chinese
39 Other Asian background
41 Mixed - White and Black Caribbean
42 Mixed - White and Black African
43 Mixed - White and Asian
49 Other Mixed background
80 Other Ethnic background
98 Do not wish to provide information
 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 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: Post Code:

Telephone: Fax:

E-mail:

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 to
Excellent Very Good Average Average 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

(PLEASE PRINT): OF REFEREE: DATE:

Thank you for completing this form. Now please return it to:
Birmingham City University, City North Campus, Admissions Division
Academic Registry, 4th Floor, Edge Building, Perry Barr, Birmingham B42 2SU