Level 3 Information Communication Technician

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Nationality*

Which programme do you wish to apply for? Please include full title of programme including qualification level (Degree, Certificate in Higher Education (CertHE))*

Please list all subjects taken, whatever the result, in chronological order. Include the qualification, subject, completion date, institution name, and result.*

Please provide a personal statement that sets out your reasons for undertaking the course. *

Name of Referee*

Student Name

• 08 Two or more impairments and/or medical conditions

• 51 A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D

• 53 A social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder

• 54 A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy

• 55 A mental health condition, such as depression, schizophrenia or anxiety disorder

• 56 A physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutches

• 57 Deaf or a serious hearing impairment

• 58 Blind or a serious visual impairment uncorrected by glasses

• 96 A disability, impairment or medical condition that is not listed above

Please enter the appropriate code if you have a disability, which may in some way affect your studies or may require special facilities or treatment.

• 10 White

• 15 Gypsy Traveller

• 21 Black or Black British – Caribbean

• 22 Black or Black British – African

• 29 Other Black background

• 31 Asian or Asian British – Indian

• 32 Asian or Asian British – Pakistani

• 33 Asian or Asian British - Bangladeshi

• 34 Chinese

• 39 Other Asian background

• 42 Mixed – White & Black African

• 43 Mixed – White & Asian

• 49 Other Mixed background

• 50 Arab

• 80 Other Ethnic background

• 90 Ethnicity not known

• 98 Prefer not to say

Please enter the code from the list of ethnic origin terms below which you feel most closely describes your ethnic origin.*