By Joel Grant,2014-05-17 17:08
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This form is for use by one person only. Please photocopy the form if more than one person wishes

    to register. Please complete all sections of this form in capital letters applications will not be processed unless this is done.

Personal Details

    Surname Mr/Mrs/Miss/Ms (please circle)

    First Names (in full) Male ? Female? Company Name and Address Home Address

Post code: Postcode:

    Telephone Telephone Number Number

    Mobile Number Mobile Number E-mail

Date of Birth

    Country of Birth



    Position held in company

Course Details (for one person only)

    Title of course Start

    Date Title of course Start

    Date Title of course Start

    Date Title of course Start

    Date Where did you hear about the courses?

Payment Details

    Fee to be paid by Method of payment Self ? Employer ? Credit Card/Invoice

    (please delete)

     All cheques made payable to University of Essex

    Credit Card Details Maestro/ MasterCard/ Visa (please delete)

    Card Number ???? ???? ???? ???? Card Verification Number (CV2) ??? Valid ??/?? Expires ??/??

Cardholder’s name (as printed on the card)………………………………………………………….

Ethnic Origin (Please mark applicable option)

    (11) White British (31) Asian or Asian British Indian (42) Mixed White and Black African (12) White - Irish (32) Asian or Asian British -Pakistani (43) Mixed White Asian (19)Other White background (33) Asian or Asian British - (49) Other Mixed background


    (21) Black or Black British -(34) Chinese or other Ethnic - (80) Other ethnic background Caribbean Chinese

    (22) Black or Black British - African (39) Other Asian background (90) Not known (29) Other Black background (41) Mixed White and Black (98) Information refused


Disabilities (Please mark applicable option)

    (00) None (04) Wheelchair user/mobility (08) Multiple disabilities


    (01) Dyslexia (05) Personal Care Support (09) A disability not mentioned above (02) Blind/partially sighted (06) Mental health difficulties (99) Prefer not to say (03) Deaf/hearing impaired (07) An unseen disability (eg

    asthma, diabetes)

Formal Learning (Please mark applicable option)

    (01) Higher degree of UK Institution (02) Postgraduate diploma or (03) PGCE with QTS/GTC registration

    certificate, excluding PGCE

    (04) PGCE without QTS/GTC (05) Postgraduate Certificate not (10) Undergraduate qualification with QTS registration elsewhere specified

    (11) First Degree of UK Institution (12) Graduate of EU Institution (13) Graduate of other overseas institution (14) GNVQ/GSVQ level 5 (15) NVQ/SVQ level 5 (16)Graduate equivalent qualification not

    specified elsewhere (21) O.U. Credit(s) (22) Other credits from UK HE (23) Certificate or diploma of education (i.e.

    institution non-graduate initial teacher training


    (24) HNC or HND (including BTEC (25) Dip HE (26) GNVQ/GSVQ level 4 and SCOTVEC equivalents

    (27) NVQ/SVQ level 4 (28) Professional qualifications (29) Foundation course at HE level (30) Other HE qualification of less (31) Foundation Degree (39) ‘A’ level equivalent qualification not

    than degree standard elsewhere specified (40) Any combinations of GCE (41) ONC or OND (including BTEC (43) Foundation course at FE Level ‘A’/SCE ‘Higher’ and GNVQ/GVSQ and SCOTVEC equivalents

    (47)Baccalaureate (55) GCSE/’O’ level qualifications (56) Other non-advanced qualification

    only; SCE ‘O’ grades and standard


    (92) Accreditation of Prior (93) Mature Student admitted on (94) Advanced Modern Apprenticeships (Experiential) Learning (APEL/APL) basis of pervious experience

    (97) Other non-UK qualification, (98) No Formal Qualification (99) Not known level not known

Data collection and protection

    The University is required to collect the information above by the Higher Education Statistical Agency. The University of

    Essex is registered under the terms of the Data Protection Act to enable it to hold and process personal data about its

    students. These data comprise details about admission, academic background, course registration and academic

    progress while at the University. They also include information collected by the University for the purposes of equal

    opportunities monitoring. The University will process these data for various administrative, academic and health and

    safety purposes. The data will be kept secure and accurate and will only be disclosed to people who have a need to know

    in accordance with the University’s registration under the Act. To enable the University to process the data held about you, would you please sign and date the declaration below.

    I certify that the information I have given is correct and I agree to the University of Essex processing personal data in

    connection with my time as a student (full or part-time) at the University for any purpose connected with my studies or my

    health and safety or for any other legitimate reason.

    Signed …………………………………………………………………………. Date ………………………….. Please return this form to Louise Cattrall, Business and Management Training Assistant,

    Business and Management Training, University of Essex, Wivenhoe Park, Colchester, Essex CO4 3SQ.

    Telephone: 01206 872519 Fax: 01206 873894 E-mail:

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