APPLICATION FORM

The information that you are submitting in this form will be held in compliance with the provisions of The Data Protection Act. Privacy Statement

Please Note: Form imput fields marked with an asterisk * are required fields and therefore must have an entry before submitting the form.

First time applicants must complete all sections but returning students may omit sections 4, 9 and 10.

Section 1

Academic Year:
*Title:
*First Name:
*Surname:	*Date of Birth:	Birth date - Month Birth date - year
Gender:	E-mail:
*Address Line 1:
*Address Line 2:
Address Line 3:
*Postcode:
*Home Phone No:
Mobile No:

* Nationality:
Have you been resident in the EU for the past 3 years?	Yes	No

Section 2

Please list the courses that you are interested in applying for (refer to prospectus for correct course title). Don't worry if you are unsure about which course you would like to take. To discuss the options available to you please call our Careers Advisor on 01432 365312.
	Course Title (in order of priority)
* First choice
Second choice
Third choice

*Mode of attendance (Full or part-time)
Undecided about what to do at College?
Would you like an informal chat with one of our Careers Advisors?	Yes No

My Future Plans
My career aim is:
I have chosen this course because:
I want to study at Herefordshire College of Technology because:

Section 3

Please give details of your current/last school or college attended
Name & address of School or College	* From	* To
* School/College	Year	Year
* Address Line 1:
Address Line 2:
Address Line 3:
* Postcode:

Section 4

Do you have any of the following qualifications prior to starting the course?
(Please tick the appropriate box)

LEVEL	QUALIFICATION
0:	Word Power / Number Power
1:	GCSE D-G or less than 5 GCSE at A-C, 1 AS Level	BTEC EDEXCEL 1st Certificate, GNVQ Foundation	NVQ Level 1	C&G Operative Award
2:	5 or more GCSE at A-C, 2 or 3 AS Level or 1 A Level	BTEC EDEXCEL 1st Diploma, GNVQ Intermediate	NVQ Level 2	C&G High Operative/Craft	RSA/OCR Diploma, Pitman Intermediate Level 2
3:	4 or more AS Level, 2 or more A Level	BTEC EDEXCEL Nat Cert/Dip, GNVQ Advanced	NVQ Level 3	C & G Advanced Craft Access to HE	RSA/OCR Stage 3 Adv Dip, ESOL Advances Award
4:	First Degree	BTEC EDEXCEL HNC/HND Other Higher Cert or Diploma	NVQ Level 4	Teaching Qualification including PGCE	RSA/OCR Advanced Certificate, RSA/OCR Higher Diploma
5:	Higher Degree	DMS, MBA	NVQ Level 5	Other professional qualification

Subject Title	Awarding Body	Grade Expected	Grade Actual
Other (please specify)
No formal qualifications

All Full Time applicants, please state all previous qualifications showing grades expected or achieved.

Subject 1	Awarding Body 1	Expected Grade 1	Actual Grade 1
Subject 2	Awarding Body 2	Expected Grade 2	Actual Grade 2
Subject 3	Awarding Body 3	Expected Grade 3	Actual Grade 3
Subject 4	Awarding Body 4	Expected Grade 4	Actual Grade 4
Subject 5	Awarding Body 5	Expected Grade 5	Actual Grade 5
Subject 6	Awarding Body 6	Expected Grade 6	Actual Grade 6
Subject 7	Awarding Body 7	Expected Grade 7	Actual Grade 7
Subject 8	Awarding Body 8	Expected Grade 8	Actual Grade 8
Subject 9	Awarding Body 9	Expected Grade 9	Actual Grade 9
Subject 10	Awarding Body 10	Expected Grade 10	Actual Grade 10

Section 5

Section 6

If you wish to supply any further information in support of your application, please use the text-box below:

Section 7

If you are applying for any of the courses listed below, please attach a supporting statement (minimum 250 words) describing why you are interested in the course and what you hope to achieve if you successfully complete it. This should be either a 'Word' document (.doc) or Rich Text Format (.rtf) or a plain text file (.txt)
BA Hons in Post Compulsory Education & Training Level 3 Diploma in Counselling Level 5 Diploma in Therapeutic Counselling Access to HE

Attach File:

Reference 1.
All applicants over the age of 17 years must provide the full names and addresses of two referees. PLEASE NOTE: This must not be a member of your immediate family.
* Name:
* Address Line 1:
Address Line 2:
Address Line 3:
* Postcode:

Reference 2.
* Name:
* Address Line 1:
Address Line 2:
Address Line 3:
* Postcode:

Section 8

Disability is defined as any physical or mental impairment which has a substantial and long term (over 12 months) adverse effect on your ability to carry out day to day activities.
Do you consider yourself to be disabled?	Yes	No
Do you have a disability or learning difficulty?	Yes	No
Please identify your support needs from the list below:

Do you require information about additional learning suppport?	Yes	No
If you are disabled, please give brief details of how we may help you. Please tell us if you need any particular arrangements to be made for your interview, or how it would be best to communicate with you (by letter, email etc).

Status

Immigration Status: (Please tick any box that applies)
	Asylum Seeker
	Refugee
	Exceptional leave to Remain/Enter
	Right of Abode/Indefinite leave to Remain or Enter
	Humanitarian Protection/Discretionary Leave

Section 9

Section 10

Once you are satisfied with your application details, please click on the 'Submit' button below:

	(01) Visual	(02) Hearing	(01) Moderate learning difficulties
	(03) Mobility	(04) Other physical	(02) Severe learning difficulties
	(05) Other medical	(06) Emotional/behavioural	(10) Dyslexia
	(07) Mental ill health	(08) Temporary disability	(11) Discalculia
	(09) Profound/Complex	(90) Multiple	(90) Multiple learning difficulties
(19) Other specific learning difficulties - please specify
(97) Other - please specify

Please help us monitor our Equality and Diversity policy. Please tick the box which you feel best describes your ethnic origin.
	Bangledeshi	African	White & Asian	White British
	Indian	Caribbean	White & Black African	Irish
	Pakistani	Other Black background	White & Black Caribbean	Any other White background
	Any other Asian background		Any other Mixed background
	Chinese
	Prefer not to say

How did you hear about HCT and the course(s) for which you are applying? (Please tick one box only)

	School	Employer	HCT Course Tutor
	HCT Prospectus	HCT School Visit	Website
	HCT Student	HCT Advertisement	HCT Information Day
	Careers Convention	Connexions Advisor	Friend/Relative
	Course Leaflets	Exhibition/Roadshow	Other

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