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Application No:
Course Application Form 2009-2010
Please fill in the form using BLOCK CAPITALS
Please indicate your ethnic origin
Course Details
Bangladeshi African White & Asian White - British Not known/
provided
Course title
Indian Caribbean White & Black African White - Irish
Full time Part time Page number
Pakistani Any other Black background White & Black Caribbean Any other White background
Personal Details
Any other Asian background Chinese Any other Mixed background Any other (please state)
Mr Mrs Miss Ms Other
qualifications: (QUALIFICATIONS RECEIVED OR EXPECTED GRADES)
Surname/Family Name:
First names:
Subject Level Expected Grade Achieved Grade Date
Example - English GCSE B 2007 Male Female Date of Birth:
D D M M Y Y Age:
Postcode:
Address:
Day time Telephone: Evening Telephone:
Mobile:
Email address:
Nationality:
Have you been living in the UK or European Economic Area, as a permanent resident for the last 3 years?
Yes No If ‘No’, where have you been living?
Do you have the following? Student Visa Student Visitor Visa
If you are 18 and under we need the name and daytime telephone number of your parent or guardian
Name:
Why do you want to do this course: (PLEASE COMPLETE)
Daytime Telephone: Mobile number:
If you are 15-19 years old please give us the following:
Name of School/College:
Address:
Postcode: Tel:
For those aged 20 years + please give us details of one referee eg employer BUT not a relative
Name:
Address:
Postcode: Tel:
Data Protection Statement
Please list Relevant Qualifications taken or to be taken INCLUDING any current college course you are attending
I agree to Henley College Coventry processing personal data contained in this form (including the Ethnic Origin and Learner Services
sections), or other data which the College may obtain from me or other people, while I am a student/applicant. The information you provide
Qualification Title Grade Date of Completion
will be shared with other organisations for the purpose of careers and other guidance.
(eg GCSE English, BT EC Introductory /First Diploma etc) (achieved /expected)
I agree to the processing of such data for any purpose connected with my application/studies or my health and safety while on the premises
or for any other legitimate reason.
I certify that the information given in this form is correct:
Signature Date
Send your application in an envelope (no stamp required) marked:
FREEPOST CV1342 Student Services, Henley College Coventry, Henley Road, Bell Green, Coventry CV2 1BR
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