CPD Short Course Application

Which short course are you applying for?

Applicant Information

Surname

Forename(s)

Previous name (if applicable)

Date of birth

Date of birth - DayDate of birth - MonthDate of birth - Year

Home address

Post code

Contact telephone number

Personal e-mail address

Work e-mail address

Employer/course fee Information

Please indicate who will be responsible for paying fees. Please tick one box.

Self funding (the invoice will be sent to your home address)

Employer (please provide the information requested below)

Organisation

Invoice address

Postcode

Contact person

Contact telephone number

e-mail address for invoice

PO number (if applicable)

Disclosure Information

Do you have any special needs? The information you provide will be treated confidentially and will not affect judgements concerning your academic suitability for the course.

If yes, please specify

Provision of information on ethnic origin is voluntary but we hope you will agree to provide it to assist us to monitor our equal opportunties policy.

As part of its equal opportunities policy, Birmingham City University monitors applications by gender, ethnic origin and disability.

Declaration

I accept that if it is discovered that I have supplied false, inaccurate or misleading information, Birmingham City University reserves the right to cancel my application, withdraw its offer of a place or terminate attendance at the University and I shall have no claim against Birmingham City University in relation thereto.

Yes

I confirm that the information given on this form is true, complete and accurate and that none of the information requested or other material information has been omitted.

Yes