<p> ACCESS APPLICATION FORM Academic Year 2016 / 2017</p><p>Please complete this form in BLACK INK and in BLOCK CAPITALS. Answer all of the questions required – enter N/A, NO or NIL where appropriate. Make sure you sign and date the application on the back page.</p><p>1 Your Personal Details </p><p>Your first names (in full)</p><p>Your surname (in full)</p><p>Your date of birth ☐☐/☐☐ /☐☐Your age on 31 August 2016 Gender M/F Your home address</p><p>Postcode</p><p>Contact Details Home phone number Mobile number Email address(s)</p><p>2 Ethnic Origin</p><p>Ethnic origin information is required as part of our monitoring of the College’s Equal Opportunities Policy – please tick the appropriate box White ☐ English/Welsh/Scottish/Northern Irish/British (31) ☐ Irish (32) ☐ Gypsy or Irish traveller (33) ☐ Any other white background (34) Mixed/Multiple ethnic group ☐White and Black Caribbean (35) ☐White and Black African (36) ☐White and Asian (37) ☐ Any other Mixed/multiple ethnic background (38) Asian/Asian British ☐ Indian (39) ☐ Pakistani (40) ☐ Bangladeshi (41) ☐ Chinese (42) ☐ Any other Asian background (43) Black/African/Caribbean/Black British ☐ African (44) ☐Caribbean (45) ☐ Any other Black/African/Caribbean background (46) Other ethnic group ☐ Arab (47) Ethnic group ☐ Any other ethnic group (48) </p><p>Have you been living in the UK or European Economic Area (EEA) for the last 3 years? ☐ YES ☐ NO</p><p>What is your nationality? </p><p>3 Criminal Convictions</p><p>Do you have any unspent criminal convictions, cautions, reprimands, final warnings or prosecutions pending? ☐ YES ☐ NO</p><p>Please turn over……… 1 4 College Have you been a full-time student at the College before? ☐ YES ☐ NO </p><p>5 Preferred subjects of interest (please circle)</p><p>Access to Health Professions Access to Humanities Access Sciences</p><p>6 Please list examinations taken / qualifications achieved. (Please include any distance or open learning courses. Start with the most recent) Awarding Body e.g. Subject(s) / Courses(s) Qualification e.g. - O Level, GCSE, Year Results (grades City & Guilds / Edexcel AS/A Level, NVQ, Access Taken if possible)</p><p>7 Career Plans Please tell us what, if any, career plans you currently have.</p><p>8 Preferred interview times, please tick AM PM Evening</p><p>9 Application Agreement The Cheadle College collects information about our staff and students for various administrative, academic and health and safety reasons. The Data Protection Act 1998 requires we ask for your consent before we do this. Since we cannot operate the College’s Admissions procedures effectively without processing information about you, we need you to sign the following consent process clause.</p><p>I agree to the College processing personal data contained in this form or any other data which the College may obtain from me or other people whilst I am a student. I also declare that to the best of my knowledge, the information given in this application is correct.</p><p>The data you provide will not be passed to any other third party without your prior consent, except where the college is required to do so by law. Any formal enquiries concerning the use of data noted here should be addressed to the Data Protection Officer.</p><p>Signature:</p><p>Date:</p><p>Please return the completed form to the: Administration Office at The Cheadle College, Cheadle Road, Cheadle Hulme, Cheshire SK8 5HA Telephone number 0161 486 4602 www.camsfc.ac.uk </p><p>2</p>