Application Form

PLEASE COMPLETE IN BLOCK CAPITALS USING A BALLPOINT PEN

Please return to:

Admissions (Student Records), Uxbridge College, Park Road,
Uxbridge, Middlesex, UB8 1NQ

Reference No. (for office use only)

1. Personal details
Surname

Mr

Mrs

Miss

Ms

First name/s
Address

Postcode

Telephone

Mobile

Email
Date of birth

(dd/mm/yy)

Age on 31 August (in the year that the course starts)

If under 18 years, name of parent or guardian

Parent or guardian contact telephone number: Home

Mobile

Country of birth
1.2 Have you been permanently resident in the UK/EU for the past three years?

Yes

(go to 1.3)

No

(go to 1.4)

1.3 Do you require a visa to study?

Yes

(go to 1.4)

No

(go to 2)

1.4 (i) Please give details of entry to the UK

(ii) How were you admitted to the UK?

(a) Student visa

(b) Visitor

(c) Refugee/asylum seeker

(d) Other, please specify

2. Monitoring information
(This is for statistical purposes only. Please indicate to which group you feel you belong.)
11 Bangladeshi

15 African

19 Mixed, White and Asian

23 White British

12 Indian

16 Caribbean

20 Mixed, White and Black African

24 White Irish

13 Pakistani

17 Black Other

21 Mixed, White and Caribbean

25 White Other

14 Asian Other

18 Chinese

22 Other Mixed Background

Other, please specify

3. Course details
I would like to be interviewed for admission to the following course:
Course name

Course code
(must be completed)

Application form continues overleaf

4. Education
Are you currently at school or college?

Yes

Application Form continued

No

If yes, please give name of school or college and tutor

4.1 Please list all the qualifications you already hold or are currently studying towards
Subject

Level (e.g. GCSE)

Date of exam

Actual/predicted grade

5. Other information
(please give details of any employment, work experience, sports, interests or hobbies)

6. Special requirements
Do you have a disability or learning difficulty?

Yes

No

If yes, please indicate what kind of disability or health issue you have
For example:

Visual impairment

Deaf

Physical disability

Aspergers/ASD

Epilepsy

Other, please specify

Dyslexia

If you would like to discuss your specific learning needs, please contact the Learning Support Team on 01895 853422.
7. Please indicate how you heard about Uxbridge College:
Banner

Employer

Hotcourses website

Open Day

Shopping Centre

Bus advert

Employment Service/Job Centre

Learndirect

Poster

Student

Careers Event

Ex-student

Live in the area

Prospectus/leaflet

Website

Careers Officer/Connexions

Facebook

Magazine advert

Relative

Other, please specify

Email

Friend/relative (word of mouth)

Newspaper

School

Notice to applicants
Under the terms of the Data Protection Act 1998, the personal information supplied by you will be treated in confidence,
but may be used internally for other registered purposes and some of the information on this form will be sent to the
Department for Education and funding agencies for statistical purposes.
I hereby declare that all the information above is correct and apply for admission to Uxbridge College.

Signature of the applicant

Date

We may use your details to contact you about College information, news and events. Please tick the box if you would prefer not to be contacted.