DIPLOMA IN ORTHODONTIC THERAPY
APPLICATION FORM
Please complete ALL sections in black ink using
BLOCK CAPITALS or type
Please complete ALL sections in black ink using
University Number:
1. PERSONAL DETAILS
BLOCK CAPITALS or type
(FOR OFFICE USE ONLY)
Last Name (family name)
(7 digits)
The name under which your file will be registered and the name you should
use on any future correspondence with us
Previous last name (if applicable)
Title
Mr/Ms/Miss/Mrs etc
Forename(s) (given names) in full
Please add all your forename(s) in the order in which they normally appear
GDC Number
Gender
Date of birth (DD/MM/YYYY)
Male
Female
Practice Address
Please indicate here if you would prefer this address to be used for
all correspondence
Postcode :
Mobile :
Telephone (Work) :
Fax :
Email :
Permanent home address
Your permanent home address. This address will also be used as
the address for correspondence
unless you
have indicated
otherwise above
Please ensure you provide an up-to-date email address here
Postcode :
Mobile :
Telephone :
Fax :
Email :
2. COURSE DETAILS
Please name of the course for which you are applying
Month and year in which you wish to start
(7 digits)
Have you ever been a student at Warwick?
Please enter your university number, if known
YES
NO
3. NATIONALITY AND RESIDENCE DETAILS
Nationality
Country of permanent residence
The country in which you have normally been resident,
except for periods of temporary absence
Please state the number of years you, your parents and,
Yourself
if applicable, your spouse, have been resident in the UK
or other EU country
Country
Country of birth
Your parents
Your spouse
Country
Country
From
From
From
To
To
To
If you are a national of a non-EU country with indefinite leave to remain in the UK please attach documentary proof e.g. letter from the Home Office
If you have been resident in more than one country please
give dates of residence in each country
If NO, please indicate the name/address of the person to invoice:
4. FINANCE
Do you expect to pay your fees yourself?
YES
NO
5. CAREER HISTORY
Please give your employment history to date or other professional experience excluding vacation work. You may
continue on a separate sheet if necessary but there is no need to go back further than 10 years.
Dates from and to
Nature of work and position held
6. LAST TWO EDUCATIONAL ESTABLISHMENTS ATTENDED
Name and address of the two most recent educational establishments
attended
Name and address of employer
From (Month /Year)
From (Month /Year)
7. ACADEMIC/PROFESSIONAL QUALIFICATION
Level, e.g. HND,
degree or
professional
qualification
Subject
Date
Month
Month Year
Year
Place of
study
Results
(grades
or
bands)
CATS
points (if
applicable)
8. REFERENCES (Please name two referees)Notes for the Guidance of Referees
The Referee’s report is an integral part of the selection process. In order that institutions can evaluate an applicant’s academic and intellectual capacity,
your reference should if possible cover:
1) Suitability for the Course applied for
3) Personal qualities
2) Intellectual qualities including:
4) Career aspirations
a) Development to date and previous examination performance
5) Social and other interests
with special reference to any factors that may in your opinion
have adversely influenced the result (if in the case of an adult
learner applicant you cannot comment on academic
Please ensure that the reference is completed in black ink or typed
performance please confine your comments to the other
issues listed).
b) Present performance
c) Potential, including an assessment of the probable results of
any pending examinations.
Name of Referee 1
Position
Address
Postcode
Telephone
Fax
Email
Name of Referee 2
Position
Address
Postcode
Telephone
Fax
Email
Please remember to enclose your named, signed and dated references with your application
9. PROFESSIONAL INTERESTS AND PURPOSE OF STUDY (Note: All applicants must complete this section)
Please use this space to describe your reasons for wishing to undertake this course. You may continue on a separate sheet if necessary
10. Source of information about Warwick
Please indicate how you heard of this course
World Wide Web
Advertisement in
(please name newspaper/journal)
Careers Office
Recommendation from Student
Poster
Employer
Friend
Prospectus
GDC
Other (please specify)
11. SPECIAL NEEDS
If you have special needs, please tick the
The University welcomes applications from people with
special needs and considers them on the same
academic grounds as those from other candidates. It is
helpful to know about your special needs in advance so
that we can discuss whether facilities are available in
the University. Applicants with special needs are
encouraged to contact the Disability Co-ordinator,
[email protected]
Dyslexia
Blind/partially sighted
Deaf/hearing impaired
An unseen special need e.g.
Diabetes, epilepsy, asthma
Other special needs please specify
Are you a registered disabled person?
12. Do you have any criminal
convictions?
For further information visit
www.warwick.ac.uk/AcademicOffice
boxes which are applicable to you:
Need Personal Care Support
Mental Health Difficulties
Wheelchair user/mobility difficulties
YES
NO
YES
NO
Asian or Asian British
Indian
Pakistani
Please help us to make our equal opportunities policy
Bangladeshi
effective by placing a tick in the box which
is
Chinese
applicable to you
Other Asian background
Mixed Race
White and black Caribbean
White and black African
White and Asian
Other mixed background
13. Equal Opportunities
Monitoring (UK students only)
Black or Black British
Caribbean
African
Other black background
White
British
Irish
Other white background
Other Ethnic Background
14. ENGLISH LANGUAGE REQUIREMENTS
All applicants whose first language is not English are required to show that their ability to understand and
express themselves in both written and spoken English is sufficiently high for them to derive full benefit from
their course of study.
The minimum score required for direct entry to the Medical School is at least 6.5 in IELTS or 600 in TOEFL
(250 in the computerised version of the test). Please attach a copy of your test certificate.
Type of test taken:
IELTS Score
TOEFL Score
WELT Score
15. DATA PROTECTION
We will only use the information you have supplied for administrative purposes. The control of this data rests primarily
with the Academic Office and transfers with the University are made on a strict ‘need to know’ basis. The University may
occasionally be requested to supply data to members of staff for research purposes, such as mailing of questionnaires.
Please tick box if you DO NOT wish your personal data to be used in this way
16. DECLARATION
I hereby apply for admission to study at the University of Warwick and I confirm that the information provided above is correct
to the best of my knowledge. I understand that any offer of admission may be withdrawn if I cannot provide documentary
evidence of any statements on this form.
Applicant’s Signature: (Please type name to return by email)
Date:
Please send completed form by email to: [email protected]
Application Checklist:
Two references
Trainer approval form
GDC membership certificate
(If not currently available, please forward as soon as possible)
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