english language application form

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					                                                                                                                   FOR OFFICE USE ONLY
                                      Application for Admission to                                                 Reg. No.

                                    English Language Programmes
                             Please return to:
                             POST: Admissions Office (c/o Isabela Fairclough), University of Central Lancashire, Preston, Lancashire PR1 2HE,
                             E-MAIL: SchoolofLIS@uclan.ac.uk / FAX: +44 (0) 1772 892 909
1. Personal details about you                                             2. More Details
Surname/Family Name :                                                    Age
                                                                          Years                Months
First Name(s) :
Home Address
                                                                           Male (M) Female (F)

                                                                           Date of Birth               /      /
                                                                                                DD / MM / YY
                                                                           Disability/special needs (refer to Guidance notes)
Postcode (UK Only)
Home contact numbers Tel:                                                  Passport number
(inc. STD/Area Code) Fax:
Email:                                                                     If you have a visa when does it expire
When can you be contacted by telephone (please give days/times) :
                                                                         Country of Permanent Residence _______________________

                                                                         Country of Birth ___________________________________
Correspondence Address (if different)
                                                                         Nationality _______________________________________

                                                                         If born outside the UK
                                                                           Date of first entry to live in the UK
Postcode (UK Only)
3. Please tick which programme you wish to apply for and when you want to study
                                                                         International Foundation programme in
Elementary English □
                                                                         Academic English Studies □
Pre-Intermediate English □
Intermediate English □

September□                   January □                    May □          September      □

Please indicate how you heard of these courses:

British Council ___                  Uclan website___                  Agent___                       Other__________________________

4. How will you pay for the course?
                                                                                                   Please tick
 i) I will be paying my own tuition fees                                                        Yes         No

 ii) My government / embassy / employer will be paying my fees*                                 Yes           No

*sponsorship letters must be in place before the start of the course
5. Do you have a physical disability or other medical condition? If yes, please give details below:

6. Your Education -                                                                                     Full time or
                                                           From (month & year)    To (month & year)
 (names of school/college/university)                                                                   Part Time

7. Your qualifications (certificates, diplomas, degrees)
                        Awarding Body
Type of Qualification   (name of the organisation who   Month   Year    Subject                        Grade
                        gave you the award)

8. Have you taken any English language test such as IELTS or TOEFL ?
                                            YES □                        NO □
If YES please give details below:

What test did you take: ________________________                 When did you take the test: ___________________

What scores did you get in each part of the test: ___________________________________________________

Overall score: ______

If IELTS exam, please give the Test Report Form number: _________________________________________
(located in the bottom right hand corner of the certificate)

9. Employment (especially any employment where you used English)
Employer                            Nature of Work                         Full-time/Part-            Dates
                                    (e.g. shop assistant, manager)         time
Present Employer (if any)

Tel. No.

Previous Employers

10. Personal Statement written by the student ONLY

I wish to do the English course because…
                          (please write as much as you can without help from anyone or a dictionary)

11. Have you been convicted of any crime?
YES    □                     NO   □
     I do not want to be contacted by the University with details of its courses or of its other products or services

Declaration: I confirm that the information given on this form is true, complete and accurate and no information
requested or other significant information has been omitted. I have read the Notes for Guidance for Completion of the
Application Form.

Your Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Date: . . . . . . . . . . . . . . . . . . . .
12.Reference (someone who can comment on your English such as your English teacher – NOT family, friends or agent)
Name of Referee
Post / Occupation / Relationship to Applicant


Tel. No. (including STD)
Fax. No. (including STD)
How long have you known the applicant and in what connection

 Can this reference be discussed with the applicant (please tick)            Yes         No
 Can this reference be revealed to the applicant (please tick)

Notes for the guidance of referees
In order to select those students who will benefit from their chosen programme of study, the University requires a supporting
statement from a referee.
Your reference about the applicant should, if possible, cover the following:
      Suitability for the course
      Oral and written ability in English
      Intellectual qualities including previous academic performance and any relevant subject experience through work/study
      Personal characteristics including evidence of ability to sustain study at level of their chosen course

Signed    ...................................            Please return by post:               Alternatively please return by:
                                                         Admissions Office (c/o Isabela
Date      ...................................            Fairclough)                             E-mail
                                                         University of Central                    (SchoolofLIS@uclan.ac.uk)
                                                         Lancashire                              Fax to office
(please affix official stamp where appropriate, at the   Preston , Lancashire, PR1 2HE            (+44 (0) 1772 892 909)
end of the statement)                                    UK

          If any part of this form is incomplete it will cause a delay in
                        your application being processed
Planning Statistics
Ethnic origin (this information will not be made available to Admissions Tutors for selection

Please choose from the ethnic origin terms printed here the one which you feel most nearly
describes your ethnic origin and write its code in the boxes

If you have used the code (19), (29), (39), (49) or (80) please describe your ethnic origin using your
own words in the space provided:

White - British                         11   Chinese or Other Ethnic background                   34
White - Irish                          12    Other Asian background                               39
Other White background                  19   Mixed - White and Black Caribbean                    41
Black or Black British - Caribbean      21   Mixed - White and Black African                      42
Black or Black British - African       22    Mixed – White and Asian                              43
Other Black background                 29    Other Mixed background                               49
Asian or Asian British – Indian        31    Other Ethnic background                               80
Asian or Asian British – Pakistani     32    Not Known                                            90
Asian or Asian British – Bangladeshi   33    Information refused                                  98

Guidance notes for completing application form
Please read these guidelines carefully before completing the form.
You should complete the form in black ink or type, ensuring that all sections are legible.
This form must be completed by the student interested in studying on the course or by an agent
acting on behalf of the student.

Section 1 Personal Details (Complete this section in BLOCK CAPITALS)
Correspondence Address - This should be an address where you may be contacted throughout the
period leading up to the start of the course. Please inform the University immediately if this
changes. If the applicant is not currently in the UK, a home address must be given, including a
contact telephone number and e-mail. Please include the most appropriate day and time when
the student can be contacted.
 The Course Leader will only accept a student if he/she is able to assess their current English
 Language ability using the completed application form and an interview either in person or on
 the telephone. If a student is already in the UK then they MUST attend a face to face interview.
 Students who have IELTS 4.5 or TOEFL (IBT) 50+ within the last 12 months are exempt from
 any interview.

Section 2 More Details
Disability/Special Needs
Information given in this section will not be used as part of the selection process.
If you have a disability or special need and may require extra support in your study, fieldwork or
accommodation please enter in the left-hand box the code from the list below that is most
appropriate to you. If more than one applies to you, please use code 8. If you have no needs
arising from your disability or special need, eg. you are short-sighted but your vision is corrected
by spectacles, use code 0. Applicants with no disabilities or special needs should also use code 0.
If you have used any code other than 0, use section 5 on page 1 of the form to describe your
disability and indicate clearly what needs you have.
Disabilities or special needs/support required
0 You do not have a disability or special need or are not aware of any additional support
  requirements in study or accommodation.
1 You have dyslexia.
2 You are blind/partially sighted.
3 You are deaf/hard of hearing.
4 You are a wheelchair user/have mobility difficulties.
5 You need personal care or assistance.
6 You have mental health difficulties.
7 You have an unseen disability, eg diabetes, epilepsy, asthma, heart condition.
8 You have two or more of the above disabilities/special needs.
9 You have a disability or special need not listed above.
20 Unspecified disability
T Autistic Spectrum Disorder
If you have a disability or learning difficulty you are strongly advised to contact our Disability
and Learning Difficulties Unit (Tel. 01772 892593) at an early stage to discuss your needs.
However, the Unit will contact you in due course.
Date of first entry to live in the UK: if you were born outside the United Kingdom, please insert
the date when you first entered the UK to live here permanently.

Section 4 Fee Payment
You should use this section to indicate the intended source of funding for tuition fee payment.
Please ensure that at least one of the alternatives is indicated.
You will be expected to provide documentary evidence of all forms of official financial support
at enrolment. Alternatively, you will be expected to make satisfactory arrangements for personal
payment of fees in full at enrolment..

Section 7 Qualifications
If possible, please provide a full transcript of any undergraduate qualifications achieved.
An English translation must be provided for a transcript of any qualification obtained outside of
the United Kingdom.

Section 10 Personal Statement

You are asked to write as much as you can in English explaining your reasons for doing the
course and how it fits into your plans for the future. Your written English MUST be your own
work and is assessed by the Course Leader as evidence of your English language ability.
 Please note that your application cannot be processed without your personal statement

Section 12 Reference
Send the original section to your chosen referee. ideally with an envelope addressed and pre-
stamped ready to send to the University by post. Alternatively, the referee can also e-mail the
reference to the course leader at zaqureshi@uclan.ac.uk or fax it to the departmental office on
+44 (0)1772 89 2909 and mark the reference for the ‘The attention of the course leader –
International Foundation Programme in Academic English Studies’

   Please note that your application cannot be processed without an academic reference
             attached or at the very least – details of a referee we can contact

If you require further information or wish to discuss your application do not hesitate to contact the Admissions Office
01772 201201.


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