Interview Request Form - 11-12:int.

form 09/04 20/01/2012 10:02 Page 1

For further information call the College Helpline

0800 074 1447

2012-2013
Forename

INTERVIEW REQUEST FORM / FULL-TIME PROGRAMMES

A
Name

PERSONAL DETAILS
Surname

Title (Mr/Mrs/Ms etc.)

Address

Postcode Email

Telephone No. Mobile No.

Date of Birth
Day Month Year Name of present or previous School or College How long have you lived in the UK? (State date of entry if less than 3 years)

PROGRAMME CHOICE
Please complete one section only, either (1), (2) or (3)

(1) If you are unsure about which programme area you would like to study and would like to talk to one of our Careers Guidance Advisers before making your decision, please tick this box:(2) If you know which programme area you want to study, please enter the programme title as shown in the Prospectus or the general vocational area, e.g. 'business', 'engineering', 'child studies' etc.

Full Programme Title or Area / code if known

Campus (please tick) Dartford Gravesend

School Leavers - please note: If you are offered an Advanced programme and do not achieve the required GCSE entry qualifications, you will be considered for a place on the Intermediate Level programme.

Predicted Subjects and Grades (if known)

I give permission for the college to contact my previous, or current school/college/employer to obtain a reference. (please tick)

Interview Request Form - 11-12:int.form 09/04 20/01/2012 10:03 Page 2

ADDITIONAL INFORMATION

Please help us identify any financial support we are able to provide in support of your studies Personal Circumstances (Please tick appropriate boxes)
Living with parents Living with lone parent Living with other relative

Living with foster parents Homeless Other (please explain)

Living with partner Traveller

Living alone In Care

Number of your dependent children

Age(s) of your dependent children

Ethnic Origin (Tick one box only) Asian or Asian British - Bangladesh Asian or Asian British - Indian Asian or Asian British - Pakistani 13 Asian or Asian British any other Asian background Black or Black British - African Black or Black British - Caribbean 16 Black or Black British anyTax Benefits other Black background Chinese Mixed - White and Asian Mixed - White and Black African 20 Mixed - White and Black Caribbean Mixed - any other Mixed background Employment and White - British Support Allowance White - Irish White - any other White background any other not known / not provided 11 12

Financial Circumstances (of carers if under 18 years)

Full-time Salary Working Tax Credit Disability Related Benefits

14 15

Part-time Salary

Job Seekers Allowance Housing/Council

17 18 19 21 22 23 24 25 98 99

Occupational Pension

Income Support

Income Related

Other benefits/ income.

Please state which:-

What is your nationality?

If you are not a British Citizen, when did you enter the United Kingdom?

ADDITIONAL SUPPORT

Day

Month

Year

Please help us identify what additional help you may need to successfully complete your programme Please tick Yes if you think you need help with: Numeracy or Maths Communications or English Examinations Do you require physical learning aids to support a disability? No No No No Yes Yes Yes Yes Yes If yes, give brief details:

Do you have any form of learning difficulty, No sensory impairment or mental health problems?

I give my permission for this information to be passed to those persons within the College who are involved in providing the Additional Support, including Teaching Staff, the Exams Office and the Learning Support Staff. Signature Date

When you have completed all the areas on this interview request form, please return in an envelope to:

Student Services, North West Kent College, FREEPOST, Dartford, Kent DA1 2BR (No stamp necessary)