CAMBRIDGE MUSLIM COLLEGE 14 St. Paul’s Road, Cambridge CB1 2EZ
T: 01223 355235 | F: 01223 355568
APPLICATION FORM for the Diploma in Contextual Islamic Studies & Leadership
2014-2015
Closing Date for Receipt: Wednesday 14th May 2014 PLEASE WRITE CLEARLY USING BLOCK LETTERS IN BLACK OR BLUE INK
1. PERSONAL DETAILS
Surname (Family Name): ………………………………………………………….… Personal Name(s): ……………………………………………………………….…… Date of Birth: ……………………………………………………………………….…. Permanent Address: …………………………………………………………………. ………………………………………………………………………………………..… ………………………………………………………………………………………..… Post Code: ………………………………… Country: ……………………………… Mobile: ……….……………………………………………………………………..… Landline.: ……………………………………..……………………………………..... Email: ……………………………………………………………………………..…… Correspondence Address (if different): ……………………………………………... ………………………………………………………………………………………….. ………………………………………………………………………….…………….… Post Code: ………………………………… Country: ……………………………….
NATIONALITY: …..………………………………………………………………… Country of Permanent Residence: …………………………………………………. If you are not a national of Britain or the European Union, what is your UK Visa Status? Please supply full details, including the type of visa you hold and its expiry date: …………….…………………………………………………….. ………………………………………………………………………….…………….… ………………………………………………………………………….…………….…
YOUR MARITAL STATUS: 2. Finance Married Single
2. FINANCE Do you wish to be considered for a scholarship?
Yes
No
If Yes: If you are not awarded a scholarship, do you propose to attend the course if admitted?
Yes
No
If Yes: What is your proposed source of finance? Personal
Other
(please give details)
……………………………………………………………………………….…………….…
………………………………………………………………………………………………... 3. PREVIOUS EDUCATION & EMPLOYMENT Please include details of your present/most current institution, as well as previous institutions attended. Institution(s) Attended (secondary level and above)
Dates of Attendance From MM/YYYY to MM/YYYY
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Please include full details of your qualifications gained. Qualification (eg GCSE, A level, BA degree)
Subject
Grade
Year
Institution
Please include full details of any positions of employment. Position of Employment, with brief details of responsibilities
Dates of Employment (From MM/YYYY to MM/YYYY)
4. OTHER EXPERIENCE Please include full details of other experience that you consider relevant to your application. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. …………………………………………………………………………………………..
5. PERSONAL STATEMENT Please write your statement here (no more than 500 words); continue on a separate sheet if necessary. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. …………………………………………………………………………………………..
6. LANGUAGES Please indicate if you speak any other languages, and the level Language
Level (written)
Level (spoken)
Qualification (if any)
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7. HEALTH & DISABILITY Do you have a health condition or dietary requirement that we should be aware of? Specifically, do you have any condition that is likely to cause you to be absent from classes on a regular basis? If yes, please give full details. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. ………………………………………………………………………………………….. …………………………………………………………………………………………..
9. DECLARATION I declare that the information given by me on this form is correct. I also agree that if admitted to the Cambridge Muslim College, I will abide by its Regulations. Signed: ……………………………………………………………………………… Date: ……………………………………………………………………………………
10. CONFIDENTIAL REFERENCE Please ensure that your references are sent to us as soon as possible after our receiving your application. References must be received by 5.00pm on Wednesday 14th May 2014. Referee 1 (academic) Name: …………………………………………………………………………………. Title: ……………
Position: ……………………………………………………….
………………………………………………………………………………………….. Phone No.: ……………………………………………………………………………. Email: …………………………………………………………………………………..
Referee 2 (academic or other) Name: …………………………………………………………………………………. Title: ……………
Position: ……………………………………………………….
………………………………………………………………………………………….. Phone No.: ……………………………………………………………………………. Email: …………………………………………………………………………………..
The applicant should send a copy of this page and the Notes for Referees to each referee. Name of Applicant: ……………………………………………………………………. Name of Referee: ………………………………………………………………………. Position: …………………………………………………………………………………. Institution/Organisation:……………………………………………………………… Address: …………………………………………………………………………………. Post Code: ……………………………………… Country: …………………………... Phone No.: ………………………………………………………………………………. Email: …………………………………………………………………………………….
Please write your statement here and continue on a separate sheet if necessary; or write on a separate sheet of the headed paper of your institution or organisation.
Signed: …………………………………………………………………………………... Date: …………………….. Official stamp: