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					Postgraduate Application Form
(Not to be used for PGDip Social Work, CPE (f/t.) MBA or PGCE applications)
The completed application form should be returned to:               For University Use only
Infozee Admissions
E-4, First Floor, Greater Kailash - I,
New Delhi – 110048, India
                                                                    Middlesex Registration No.:
Tel: + 91 - 11 - 51831442                                           Regional Office Number:
Email: mxadmission@infozee.com


Title: Mr/Mrs/Miss/Ms/Other                                          Nationality
Surname/Family name (BLOCK CAPITALS)                                 Country of Birth

                                                                     Country of Permanent Residence

First name(s)                                                        The following must be completed :

                                                                      Have you been granted permanent residence
Previous surname (if changed)                                         in the EU?            YES/NO


Date of birth                                                         Date on which this was granted:
                                                                     Please state how you are intending to fund your
Gender:                    Male                Female
                                                                     studies:
Address (for correspondence)



                                                                     Disability: Please select the most appropriate code
                                                                     0 None
                                                                     1 Dyslexia
Telephone (Home)                           Telephone (Mobile)        2 Blind or partially sighted
                                                                      3 Deaf or hearing impaired
                                                                      4 Wheelchair user or mobility difficulties
Fax                                         Email
                                                                      5 Personal care support
                                                                      6 Mental health difficulties
                                                                      7 Unseen disability e.g. Diabetes, Epilepsy, Asthma
Permanent address (if different from above)
                                                                      8 Multiple disabilities
                                                                      9 Other disab ility
                                                                     Please provide details of any disabilities that require special
                                                                     support:


If you have previously studied at Middlesex University please give your student number :

Ethnic Origin This information is required for equal opportunities monitoring only; please circle the appropriate
Census Category
Asian/Asian British-Indian                       Other Black Background                                 Mixed White/Black -African'
Asian/Asian British-Pakistani                   Chinese or other ethnicity/Chinese                   Mixed White/Black -Caribbean
Asian/Asian British-Bangladeshi                           White-British                                  Other mixed b ackground
Other Asian Background                                    White-Irish                                   Other Ethnic Background
Black/Black British-African                       Other White Background                                            Not Kno wn
Black/Black British-Caribbean                          Mixed White/Asian                                         Information Refused

Programme applied for: (If applying for more than one, please list in order of preference. Applications will be considered
sequentially)

  Programme Title                                                      Module Code                                 Proposed Start Date
                                                                      (if appropriate)                             Septem ber/January
         Qualifications           Duration (Years from • to)      Name of Institution (Please         Subjects and grades
                                                                  give town/country, if not UK)


English Language qualification
(i.e.; QCSE, IELTS, TOEFL


Class 10th/'0' Level



12th Std/'A'Le vel/ Higher
Secondary

Graduation


Post Graduation/Diploma/
Others

Applicants should enclose full transcripts of previous study. Applicants whose first language is not English must
enclose a copy of their most recent English language test results.
   Qualifications Pending
    Name of qualification         Anticipated date of award       Name of Institution (Please          Predicted results
                                                                  give town/country if not UK)




Current work experience
Name of current employer
Length of time with current employer                           Years                              Months
Current job title
Explain your current job and responsibilities




                                          (Continue on separate sheet if required)

Previous Work Experience
Approximate dat es: (from - to)              Employer's Name and Address                           Nature of Employment
Reference: Please complete the details of the two referees below and submit both references on headed
paper with official stamps (where appropriate). The first reference must be academic and the second shoul d
preferably be a work reference.
First Referee :                                         Second Referee :
 Title : Dr/Mr/Mrs/Miss/Ms/Other                           Title: Dr/Mr/Mrs/Miss/Ms/Other
 Surname/Family name (B LOCK CAPITA LS)                    Surname/Family name (B LOCK CAPITA LS)
 First Name


                                                           First Name

Occupation                                               Occupation

Relationship to applicant                                Relationship to applicant

Address                                                  Address




Telephone                             Fax                Telephone                           Fax

E-mail                                                   E-mail
Where did you hear about Middlesex University?
INFOZEE – www.infozee.com , Edyonder, 156 Severne road, Acocks Green, Birmingham B27 7HR, U.K.

Applicant Checklist
 Have you signed and dated your application?

 Have you included the following documents :

Transcripts (if appropriate)
Two references
English language qualification (if appropriat e)



If you have applied for an Art and Design programme programmer please include the following if appropriate:

 Project proposal
 Portfolio
 What happens next?

 Provided we have received all the required documentation, you will be contacted within three weeks of rec eipt of
 your application form.
 OFFICE USE ONLY
  Personal statement (Please give reasons for choosing thi s programme of study, you may also wish to
  include details of what you have read about the subject, other achievements and your future plans).




Note : Any statements on this form which prove to be untrue or purposely misleading will cause any subsequent
offer or enrolment at the University to be null and void.

Declaration:
I confirm that the information given in this form is true, complete and accurate: no information requested or other material
information has been omitted. I consent to the processing of this data by Middlesex University for educational purposes
under the provision of the 1998 Data Protection Act.

Applicant's Signature _________________________________________________ Date __________________

				
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