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
E-4, First Floor, Greater Kailash - I,
New Delhi – 110048, India
Middlesex Registration No.:
Tel: + 91 - 11 - 51831442 Regional Office Number:
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
Address (for correspondence)
Disability: Please select the most appropriate code
Telephone (Home) Telephone (Mobile) 2 Blind or partially sighted
3 Deaf or hearing impaired
4 Wheelchair user or mobility difficulties
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
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
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
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
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.
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)
Relationship to applicant Relationship to applicant
Telephone Fax Telephone Fax
Where did you hear about Middlesex University?
INFOZEE – www.infozee.com , Edyonder, 156 Severne road, Acocks Green, Birmingham B27 7HR, U.K.
Have you signed and dated your application?
Have you included the following documents :
Transcripts (if appropriate)
English language qualification (if appropriat e)
If you have applied for an Art and Design programme programmer please include the following if appropriate:
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.
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 __________________