CA M BR IDGE M USL IM CO L LE GE

14 St. Paul’s Road, Cambridge CB1 2EZ T: 01223 355235 | F: 01223 355568

APPLICATION FORM for the Diploma in Contextual Islamic Studies & Leadership

2014-2015

Closing Date for Receipt: Wednesday 14th May 2014

PLEASE WRITE CLEARLY USING BLOCK LETTERS IN BLACK OR BLUE INK

1. PERSONAL DETAILS

Surname (Family Name): ………………………………………………………….…

Personal Name(s): ……………………………………………………………….……

Date of Birth: ……………………………………………………………………….….

Permanent Address: ………………………………………………………………….

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Post Code: ………………………………… Country: ………………………………

Mobile: ……….……………………………………………………………………..…

Landline.: ……………………………………..…………………………………….....

Email: ……………………………………………………………………………..……

NATIONALITY: …..…………………………………………………………………

Country of Permanent Residence: ………………………………………………….

If you are not a national of Britain or the European Union, what is your UK

Visa Status? Please supply full details, including the type of visa you hold

and its expiry date: …………….……………………………………………………..

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Correspondence Address (if different): ……………………………………………...

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Post Code: ………………………………… Country: ……………………………….

2. Finance

2. FINANCE

3. PREVIOUS EDUCATION & EMPLOYMENT

YOUR MARITAL STATUS:

Married Single

Please include details of your present/most current institution, as well as previous

institutions attended.

Institution(s) Attended (secondary level and above) Dates of Attendance

From MM/YYYY to MM/YYYY

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Do you wish to be considered for a scholarship? Yes No

If Yes: If you are not awarded a scholarship, do you propose to attend the course if

admitted? Yes No

If Yes: What is your proposed source of finance?

Personal Other

(please give details)

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Please include full details of your qualifications gained.

Qualification (eg GCSE, A level, BA degree)

Subject Grade Year Institution

Please include full details of any positions of employment.

Position of Employment, with brief details of responsibilities

Dates of Employment (From MM/YYYY to MM/YYYY)

4. OTHER EXPERIENCE

Please include full details of other experience that you consider relevant to your application.

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5. PERSONAL STATEMENT

Please write your statement here (no more than 500 words); continue on a separate

sheet if necessary.

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6. LANGUAGES

7. HEALTH & DISABILITY

Please indicate if you speak any other languages, and the level Language Level Level Qualification (if any) (written) (spoken)

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Do you have a health condition or dietary requirement that we should be aware of? Specifically, do you have any condition that is likely to cause you to be absent from classes on a regular basis? If yes, please give full details. …………………………………………………………………………………………..

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9. DECLARATION

10. CONFIDENTIAL REFERENCE

Please ensure that your references are sent to us as soon as possible after our receiving your application. References must be received by 5.00pm on Wednesday 14th May 2014.

I declare that the information given by me on this form is correct. I also agree that if admitted to the Cambridge Muslim College, I will abide by its Regulations.

Signed: ………………………………………………………………………………

Date: ……………………………………………………………………………………

Referee 1 (academic)

Name: ………………………………………………………………………………….

Title: …………… Position: ……………………………………………………….

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Phone No.: …………………………………………………………………………….

Email: …………………………………………………………………………………..

Referee 2 (academic or other)

Name: ………………………………………………………………………………….

Title: …………… Position: ……………………………………………………….

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Phone No.: …………………………………………………………………………….

Email: …………………………………………………………………………………..

The applicant should send a copy of this page and the Notes for Referees to each referee.

Name of Applicant: …………………………………………………………………….

Name of Referee: ……………………………………………………………………….

Position: ………………………………………………………………………………….

Institution/Organisation:………………………………………………………………

Address: ………………………………………………………………………………….

Post Code: ……………………………………… Country: …………………………...

Phone No.: ……………………………………………………………………………….

Email: …………………………………………………………………………………….

Please write your statement here and continue on a separate sheet if necessary; or write on a separate sheet of the headed paper of your institution or organisation.

Signed: …………………………………………………………………………………... Date: …………………….. Official stamp: