Admissions use only:
Agent code
Undergraduate direct entry
application form
Return form to:
School of Nursing
[email protected]
This form should only be used for entry onto a programme with a ‘direct entry’ agreement.
Please complete the form in CAPITAL LETTERS in black ink.
1. Personal details and contact information
Title (Mr, Mrs, Ms, Miss etc)
Gender
Male
Female
Last/family name/surname
Forenames/given names
Date of birth
D
D
M
M
Y
Y
Ethnic origin (please see section 1. iii of the guidance notes)
Permanent home address
Post/zip code
Country
Telephone numbers:
Home
Mobile
Email address
Correspondence/temporary address
(if different from your home address)
From
D
D
M
M
Y
Y
to
Post/zip code
Country
Telephone number
Fax number
Do you have a criminal conviction? (See section 1. v of the guidance notes) If yes, please give details
Yes
No
D
D
M
M
Y
Y
2
2. Proposed programme of study
Qualification applied for (ie. MEng, BEng, BSc, BA)
Point of entry (ie. year 2/3)
Programme title
Y
Year of entry
3. Nationality and residence details
Nationality
If you have dual nationality please enter your second nationality
Country of birth
Country of permanent residence
UK/EU nationals only – Have you, apart from holidays, lived continuously in the UK or EU for the past three years
If No, in which other countries have you lived? Please give details and dates.
Yes
No
If you are a non-EU national with indefinite leave to remain in the UK please attach documentary proof, eg. a photocopy of a letter
from the Home Office. Please do not send original documents.
Do you require a student visa in order to study in the UK?
Yes
No
If Yes and you currently have a passport, please provide a copy of your passport personal details
page with your application, tick if included
Yes
No
4. Disability (including dyslexia or health conditions)
The University of Birmingham has long been committed to supporting students with disabilities, including dyslexia
or health conditions.
Please select the most appropriate code listed on section 4 of the guidance notes
If you have a disability please give details of any special requirements or additional support needs.
Y
Y
Y
3
5. Education – qualifications already held/to be obtained
University/College/Institution
Dates of attendance
and whether full-time
or part-time
Programme of
current study
Subjects
Classification/
Score/Grade/
GPA
Please tick if a transcript is included with your application
6. English language proficiency
If your first language is not English please give details of any recognised English language qualifications you have obtained or expect to obtain before
admission.
Qualification
(eg. IELTS, TOEFL, GCSE)
Date test taken
or to be taken
Grade or Score
(if known)
4
8. Declaration
I confirm that the information given on this form is true, complete and accurate and that no information has been omitted. I accept that if this is not
the case the University of Birmingham shall have the right to cancel my application and that I shall have no claim against the University
of Birmingham. I give my consent to the storage and processing of this data by the University of Birmingham.
Signed
Edgbaston, Birmingham,
B15 2TT, United Kingdom
www.bham.ac.uk
Date
4778 © University of Birmingham 2010. Printed on a recycled grade paper containing 100% post-consumer waste.
7. Any other information