Diploma in orthodontic therapy application form



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DIPLOMA IN ORTHODONTIC THERAPY

APPLICATION FORM

Please complete ALL sections in black ink using BLOCK CAPITALS or type





  1. PERSONAL DETAILS

University Number: (FOR OFFICE USE ONLY)

(7 digits)

Last Name (family name)

The name under which your file will be registered and the name you should use on any future correspondence with us



     

Previous last name (if applicable)

     

Title

Mr/Ms/Miss/Mrs etc



     

Forename(s) (given names) in full

Please add all your forename(s) in the order in which they normally appear



     

GDC Number

     


Date of birth (DD/MM/YYYY)

     

Gender

Male 

Female 

Practice Address

Please indicate here if you would prefer this address to be used for all correspondence



     

     

     

Postcode :

   


Mobile :

     


Telephone (Work) :

     


Fax :

     


Email :      

Permanent home address

Your permanent home address. This address will also be used as

the address for correspondence unless you have indicated
otherwise above


     

     

     

Postcode :

     


Mobile :

     


Telephone :

     


Fax :

     


Please ensure you provide an up-to-date email address here

Email :

     


  1. COURSE DETAILS

Please name of the course for which you are applying

     

Month and year in which you wish to start

     

Have you ever been a student at Warwick?

Please enter your university number, if known



YES 

NO 

(7 digits)

     


  1. NATIONALITY AND RESIDENCE DETAILS

Nationality

     

Country of permanent residence

The country in which you have normally been resident, except for periods of temporary absence



     

Country of birth

     

Please state the number of years you, your parents and, if applicable, your spouse, have been resident in the UK or other EU country

Yourself      

Your parents      

Your spouse      

Country      

Country      

Country      

From      

From      

From      

To      

To      

To      

If you are a national of a non-EU country with indefinite leave to remain in the UK please attach documentary proof e.g. letter from the Home Office

If you have been resident in more than one country please give dates of residence in each country

     

     

     

  1. FINANCE

Do you expect to pay your fees yourself? YES  NO 

If NO, please indicate the name/address of the person to invoice:

     









5. CAREER HISTORY

Please give your employment history to date or other professional experience excluding vacation work. You may continue on a separate sheet if necessary but there is no need to go back further than 10 years.



Dates from and to

Nature of work and position held

Name and address of employer

     

     

     

     

     

     

     

     

     

     

     

     



  1. LAST TWO EDUCATIONAL ESTABLISHMENTS ATTENDED Name and address of the two most recent educational establishments attended

From (Month /Year)

From (Month /Year)

     

     

     

     

     

     

     

     

     

     



  1. ACADEMIC/PROFESSIONAL QUALIFICATION

Level, e.g. HND, degree or professional qualification

Subject

Date

Month


Year

Place of
study

Results (grades or bands)

CATS points (if applicable)

Month

Year


     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     






8. REFERENCES (Please name two referees)Notes for the Guidance of Referees

The Referee’s report is an integral part of the selection process. In order that institutions can evaluate an applicant’s academic and intellectual capacity, your reference should if possible cover:



  1. Suitability for the Course applied for 3) Personal qualities

  2. Intellectual qualities including: 4) Career aspirations

  1. Development to date and previous examination performance 5) Social and other interests
    with special reference to any factors that may in your opinion

have adversely influenced the result (if in the case of an adult

learner applicant you cannot comment on academic Please ensure that the reference is completed in black ink or typed


performance please confine your comments to the other

issues listed).



  1. Present performance

  1. Potential, including an assessment of the probable results of
    any pending examinations.

Name of Referee 1      

Position      

Address      

     

Postcode      

Telephone      

Fax      

Email      

Name of Referee 2      

Position      

Address      

     

Postcode      

Telephone      

Fax      

Email      

Please remember to enclose your named, signed and dated references with your application



9. PROFESSIONAL INTERESTS AND PURPOSE OF STUDY (Note: All applicants must complete this section)

Please use this space to describe your reasons for wishing to undertake this course. You may continue on a separate sheet if necessary

     








  1. Source of information about Warwick

Please indicate how you heard of this course

 Advertisement in

(please name newspaper/journal)

     


 World Wide Web

 Careers Office

 Recommendation from Student

 Poster

 Employer

 Friend

 Prospectus

 GDC

 Other (please specify)       

  1. SPECIAL NEEDS

The University welcomes applications from people with special needs and considers them on the same academic grounds as those from other candidates. It is helpful to know about your special needs in advance so that we can discuss whether facilities are available in the University. Applicants with special needs are

encouraged to contact the Disability Co-ordinator,


disability@warwick.ac.uk

If you have special needs, please tick the

 Dyslexia

 Blind/partially sighted

 Deaf/hearing impaired

 An unseen special need e.g.

Diabetes, epilepsy, asthma



boxes which are applicable to you:

 Need Personal Care Support

 Mental Health Difficulties

 Wheelchair user/mobility difficulties



 Other special needs please specify

     

Are you a registered disabled person?

YES 

NO 

  1. Do you have any criminal convictions?

For further information visit

www.warwick.ac.uk/AcademicOffice

YES 

NO 

  1. Equal Opportunities Monitoring (UK students only)

Please help us to make our equal opportunities policy

effective by placing a tick in the box which is


applicable to you

Asian or Asian British

 Indian


 Pakistani

 Bangladeshi

 Chinese

 Other Asian background



Black or Black British

 Caribbean

 African

 Other black background



Mixed Race

 White and black Caribbean

 White and black African

 White and Asian

 Other mixed background


White

 British

 Irish

 Other white background



 Other Ethnic Background

  1. ENGLISH LANGUAGE REQUIREMENTS

All applicants whose first language is not English are required to show that their ability to understand and express themselves in both written and spoken English is sufficiently high for them to derive full benefit from their course of study.

The minimum score required for direct entry to the Medical School is at least 6.5 in IELTS or 600 in TOEFL (250 in the computerised version of the test). Please attach a copy of your test certificate.

Type of test taken: IELTS Score TOEFL Score WELT Score


  1. DATA PROTECTION

We will only use the information you have supplied for administrative purposes. The control of this data rests primarily with the Academic Office and transfers with the University are made on a strict ‘need to know’ basis. The University may occasionally be requested to supply data to members of staff for research purposes, such as mailing of questionnaires. Please tick box if you DO NOT wish your personal data to be used in this way

  1. DECLARATION

I hereby apply for admission to study at the University of Warwick and I confirm that the information provided above is correct to the best of my knowledge. I understand that any offer of admission may be withdrawn if I cannot provide documentary evidence of any statements on this form.

Applicant’s Signature: (Please type name to return by email)
     

Date:

     




Application Form Orthodontic Therapists v4-Feb16
Please send completed form by email to: dentists@warwick.ac.uk
Application Checklist:  Two references

 Trainer approval form

 GDC membership certificate

 Indemnity insurance certificate



(If not currently available, please forward as soon as possible)



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