Local Student Application Application Form All the information you give us is confidential. Local Student ApplicationProgramme applied forStart dateDate of application Full Time Part TimePersonal DetailsFirst NameLast NameDate of BirthPreferred NamePlace of BirthDo you regard English as your second language- Select -YesNoIf yes, what is your first languageContact DetailsHome AddressHow long have you lived at this address?PostcodeYour OccupationPlease state who is intending to pay your fees:- Select -Career Development LoanYourselfEmployerStudent Finance CompanyOtherWhere did you hear about the course?QualificationsPlease give details of any qualifications already obtained, exams still to be taken or courses completed. Predicted grades to be entered by school/college refereeSubject or courseLevel (GCSE, A Level etc.)Start dateEnd dateGrade achieved (If course completed)Grade predicted (If results not yet known)Higher Education/TrainingStart dateEnd dateEstablishment (Name, Town, Country)Qualifications gained (Name, Town, Country)Voluntary WorkStart dateEnd datePosition held & nature of workName & address of employerEmploymentEmployment FromEmployment ToPosition held & nature of workName & address of employerSupporting statement/experience relevant to course applied for:Interests/hobbies:Please help us to monitor our Equal Opportunities policy by completing this sectionI consider my ethnic origin to be- Select -English/Welsh/Scottish/Northern Irish/BritishPakistaniIrishBangladeshiGypsy or Irish TravellerChineseAny other White BackgroundAny other Asian BackgroundWhite & Black CaribbeanAfricanWhite & Black AfricanCaribbeanWhite & AsianAny other Black/African/Caribbean BackgroundAny other mixed/multiple ethnic backgroundArabIndianAny other ethnic groupLearning difficulty or any specific extra support requirements?- Select -No learning difficulty (97)Other specific learning difficulty (19)Moderate learning difficulty (01)Autism spectrum disorder (20)Severe learning difficulty (02)Multiple learning difficulties (90)Dyslexia (10)Other (97)Dyscalculia (11)Do you want to discuss your learning needs with a member of staf- Select -YesNoDo you have a disability or any specific extra support requirements?- Select -No disability (98)Visual impairment (01)Hearing impairment (02)Disability affecting mobility (03)Other physical disability (04)Other medical conditionEmotional/behavioural difficulties (06)Mental health difficulty (07)Temporary disability after illness (eg post viral) or accident (08)Profound complex disabilities (09)Aspergers syndrome (10)Multiple disabilities (90)Other (97)Please state any specific extra support you may require:Residency statusHave you been permanently resident in the UK or EU for three years prior to 31st August (prior to course start date)?- Select -YesNoPlease complete all relevant details:British National- Select -YesNoEU/EEA Resident- Select -YesNoIndefinite leave to remain- Select -YesNoCountry of residenceSelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweDate of entry to UK/EU/EEA (if applicable) :Visa- Select -YesNoVisa type- Select -ResidenceVisitVisa Start dateVisa End dateVisa conditionNationalityEmployment statusAll Learners- Select -In paid employmentNot in paid employment, looking for work and available to start workNot in paid employment, not looking for work e.g. school leaver/retired and/or not available to start workIn full time education or training prior to enrolmentEmployed for 20 hours or more per weekEmployed for 16-19 hours per weekEmployed for less than 16 hours per weekSelf employedIf employed, please state for how long- Select -up to 3 months4-6 months7-12 months12 months or moreIf unemployed, please state for how long- Select -less than 6 months6-11 months12-23 months24-35 months36 months or moreI am in receipt of Job Seekers Allowance (JSA)I am in receipt of Employment and Support Allowance (ESA WRAG)I am in receipt of Universal CreditI am in receipt of another state benefit (other than JSA or ESA WRAG)I am not in receipt of any state benefitSubmit Form
