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I would like to apply for *

 Full-time Weekend - April 2012
 Full-time Weekday - September 2012
 Part-time Weekday - September 2012

BSc Hons Acupuncture | School of Health and Social Care | A Partner College of the University of Greenwich

Surname *

First Name *

Preferred Name

Name on qualifications (if different)

 Male *
 Female

Date of Birth * - DD/MM/YYYY

Nationality *

If you are not a British Citizen or a Citizen of a European Community member country, please tick this box:  If you will be residing in the UK while on this course, please give details of arrangements made with the Home Office regarding your residency in Britain.

Profession *

Email Address *

Telephone number *
Home  
Mobile  

Home Address (non term) *

Contact Address (during term if known)

Where did you first hear about the college? *

Do you have any previous study / experience of Acupuncture or other holistic therapies? *
Please provide details below including start / end dates

Professional / Work Experience to date *
Please provide details below including Company Name, Position & Details, start / end date

Formal Education *
Please give details of any GCSEs and 'A' levels, NVQ or equivalent and degree or further education qualifications which involved examinations.
Please note that original certificates will need to be seen at interview

State your reason for wanting to study acupuncture and your suitability to become a practitioner *

Please provide a Reference *
Name *

Address *

Telephone Number *

In what capacity is this person known to you? *

The referee should be a person known in a professional or academic capacity (i.e. not a friend or family member)

Please write a statement declaring your health status *
Include information about any health issue or disability that may hinder or prevent your learning so that we can determine any support that you may need.

CRIMINAL OFFENCE DECLARATION *
Have you been convicted of, cautioned for or charged with any criminal offence? Conviction includes being put on probation or being given an absolute or conditional discharge or being bound over or being given formal caution. This includes convictions which would normally be regarded as spent under the Rehabilitation of Offenders Act 1974.

YES NO 

If YES, please give full information about the nature of the offence, the date of conviction or caution and the sentence.
Details:



DATA PROTECTION ACT 1998
The information which you give will be used for the following purposes: to enable ICOM and our partner, the University of Greenwich, to create a computer and paper record of your application; to enable the application to be processed; to enable the institution to compile statistics, or to assist other organisations to do so, provided that no statistical information that would identify you as an individual will be published. The information will be kept securely, and will be kept no longer than necessary.

I declare, to the best of my knowledge and belief, that the information I have given in this application is true. I am aware that if I am offered an unconditional place on the course I will be required to complete a form for the Criminal Records Bureau (CRB) that will be sent to me by the University. I understand that I must submit the CRB form as soon as possible in order to participate in clinic practice learning. I understand that a record of a criminal offence for which I have been convicted, cautioned or charged may prevent me from being permitted to complete the course or subsequently being eligible for state registration.

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