APPLICATION FORM 2014-15
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CAMBR IDGE M USLIM COLLE GE<br />
14 St. Paul’s Road, Cambridge CB1 2EZ T: 01223 355235 | F: 01223 355568<br />
<strong>APPLICATION</strong> <strong>FORM</strong><br />
for the Diploma in Contextual Islamic Studies & Leadership<br />
<strong>2014</strong>-20<strong>15</strong><br />
Closing Date for Receipt: Wednesday 14 th May <strong>2014</strong><br />
PLEASE WRITE CLEARLY USING BLOCK LETTERS IN BLACK OR BLUE INK<br />
1. PERSONAL DETAILS<br />
Surname (Family Name): ………………………………………………………….…<br />
Personal Name(s): ……………………………………………………………….……<br />
Date of Birth: ……………………………………………………………………….….<br />
Permanent Address: ………………………………………………………………….<br />
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Post Code: ………………………………… Country: ………………………………<br />
Mobile: ……….……………………………………………………………………..…<br />
Landline.: ……………………………………..…………………………………….....<br />
Email: ……………………………………………………………………………..……<br />
Correspondence Address (if different): ……………………………………………...<br />
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Post Code: ………………………………… Country: ……………………………….<br />
NATIONALITY: …..…………………………………………………………………<br />
Country of Permanent Residence: ………………………………………………….<br />
If you are not a national of Britain or the European Union, what is your UK<br />
Visa Status? Please supply full details, including the type of visa you hold<br />
and its expiry date: …………….……………………………………………………..<br />
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YOUR MARITAL STATUS:<br />
2. Finance<br />
Married<br />
Single<br />
2. FINANCE<br />
Do you wish to be considered for a scholarship? Yes No<br />
If Yes: If you are not awarded a scholarship, do you propose to attend the course if<br />
admitted? Yes No<br />
If Yes: What is your proposed source of finance?<br />
Personal Other (please give details)<br />
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3. PREVIOUS EDUCATION & EMPLOYMENT<br />
Please include details of your present/most current institution, as well as previous<br />
institutions attended.<br />
Institution(s) Attended (secondary level and above)<br />
Dates of Attendance<br />
From MM/YYYY to MM/YYYY<br />
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Please include full details of your qualifications gained.<br />
Qualification<br />
(eg GCSE, A level,<br />
BA degree)<br />
Subject Grade Year Institution
Please include full details of any positions of employment.<br />
Position of Employment, with brief details of<br />
responsibilities<br />
Dates of<br />
Employment<br />
(From MM/YYYY to<br />
MM/YYYY)
4. OTHER EXPERIENCE<br />
Please include full details of other experience that you consider relevant to<br />
your application.<br />
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5. PERSONAL STATEMENT<br />
Please write your statement here (no more than 500 words); continue on a separate<br />
sheet if necessary.<br />
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6. LANGUAGES<br />
Please indicate if you speak any other languages, and the level<br />
Language Level Level Qualification (if any)<br />
(written) (spoken)<br />
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7. HEALTH & DISABILITY<br />
Do you have a health condition or dietary requirement that we should be<br />
aware of? Specifically, do you have any condition that is likely to cause you to<br />
be absent from classes on a regular basis? If yes, please give full details.<br />
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9. DECLARATION<br />
I declare that the information given by me on this form is correct. I also agree<br />
that if admitted to the Cambridge Muslim College, I will abide by its<br />
Regulations.<br />
Signed: ………………………………………………………………………………<br />
Date: ……………………………………………………………………………………<br />
10. CONFIDENTIAL REFERENCE<br />
Please ensure that your references are sent to us as soon as possible after<br />
our receiving your application. References must be received by 5.00pm on<br />
Wednesday 14 th May <strong>2014</strong>.<br />
Referee 1 (academic)<br />
Name: ………………………………………………………………………………….<br />
Title: …………… Position: ……………………………………………………….<br />
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Phone No.: …………………………………………………………………………….<br />
Email: …………………………………………………………………………………..<br />
Referee 2 (academic or other)<br />
Name: ………………………………………………………………………………….<br />
Title: …………… Position: ……………………………………………………….<br />
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Phone No.: …………………………………………………………………………….<br />
Email: …………………………………………………………………………………..
The applicant should send a copy of this page and the Notes for Referees to<br />
each referee.<br />
Name of Applicant: …………………………………………………………………….<br />
Name of Referee: ……………………………………………………………………….<br />
Position: ………………………………………………………………………………….<br />
Institution/Organisation:………………………………………………………………<br />
Address: ………………………………………………………………………………….<br />
Post Code: ……………………………………… Country: …………………………...<br />
Phone No.: ……………………………………………………………………………….<br />
Email: …………………………………………………………………………………….<br />
Please write your statement here and continue on a separate sheet if necessary; or write on a<br />
separate sheet of the headed paper of your institution or organisation.<br />
Signed: …………………………………………………………………………………...<br />
Date: …………………….. Official stamp:
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