SIR JOHN CASS’S FOUNDATION
LORD MAYOR’S SCHOLARSHIP PROGRAMME
APPLICATION FORM 2011 - 2012
Sir John Cass’s
Foundation
Established 1748
Please read the accompanying guidance notes to check you are eligible to apply
before completing this application form. Please answer every question and write
clearly in black ink.
ABOUT YOU
Title: Mr
Mrs
Miss
Ms
First name/s
Family / Last name
Permanent home address:
Student Number:
Date of birth:
Age:
Place of birth:
Nationality:
London Borough:
Length of time at this address:
If less than three years, please provide details of the other addresses you lived at in the last three years,
including the dates you lived there:
Phone number:
Email address (please write clearly)
Mobile number:
Term time address if different from above:
Is your permanent home:
One parent home
Two parent home
With guardian/s
With friends
With a partner
or spouse
By yourself
Other, please specify
Type of home:
Flat
How many bedrooms:
How many people live there:
House
Other, please specify
YOUR FAMILY
Number of brothers and sisters who live with you:
Their ages:
Their ages:
How many of these are still in education:
If you have children please tell us:
How many children you have:
Are you a single parent?
Yes
Their ages:
No
Your household income
If you live with you parents please list all their income below (including wages, different types of benefits,
maintenance payments etc).
If you live independently of your parents and live with a partner/spouse please list all their income below.
Who
Type of income
Amount they get before deductions
e.g. self, mother, partner etc
e.g. salary, pension, benefits
State whether weekly, monthly or
annually
YOUR EDUCATION SINCE THE AGE OF ELEVEN
From
To
Name and address of
school(s) and/or college(s)
Subjects studied
Qualifications/Grades
In order for your application to be considered, a copy of your UCAS form is required. Please enclose a copy if
available, or if you do not have a copy, please tick the box to give permission to City University London to
provide the Sir John Cass’s Foundation with our archived copy of your UCAS form.
“I confirm that I give permission to City University London to provide Sir John Cass’s Foundation with a copy of
my UCAS form.”
(please tick)
COURSE APPLIED FOR/CURRENT COURSE AT CITY UNIVERSITY LONDON
UCAS Code:
Course Title:
YOUR EMPLOYMENT
Current and previous employment, voluntary work and work experience
From
To
Position/Job Title
Name of Employer
Type of employment
paid, voluntary, work experience
Please tell us about any voluntary work you listed above
Other Funding
Other Charities, Trusts, Foundations or Funds you have applied to for funding
Name of organisation
Date applied
Result, if known
YOUR STATEMENT
Please use the space below to write your personal statement to support your application. It is
important to the bursary committee for you to include information about your interests, your
academic and career plans, your family circumstances, any special reasons why you think you should
be considered for an award and any other information that you feel might be useful or interesting. You
may add an additional page to this application if required.
DECLARATION
The information I have given on this form is complete and accurate to the best of my knowledge and belief:
Signed
Date
Please return your completed application form to:
Tom Pearson
Student Centre Level 2
City University London
Northampton Square
London
EC1V 0HB
By Friday, 30th September 2011
DOCUMENTS YOU NEED TO SEND US WITH YOUR APPLICATION
Please enclose photocopies of the following:

your most recent SFE assessment letter

correspondence regarding any applications you have made for Access to Learning
funds or other college awards – e.g. scholarships or bursaries

proof of your parents’/guardian’s/partner’s income if you do not yet have an assessment
letter from SFE (wage slip, copy of P60, benefit letters, child benefit letter)

proof of your own income if you do not yet have an assessment letter from SFE
Please enclose original copies of the following:

a reference from a current or recent academic tutor

a second suitable reference (for example UCAS, employer or other independent
person)
If you think you qualify, please send your completed application form with the documents
listed above to:
Please return your completed application form to:
Tom Pearson
Student Centre Level 2
City University London
Northampton Square
London
EC1V 0HB
By Friday, 30th September 2011
SIR JOHN CASS’S FOUNDATION
ESTABLISHED 1748
INDIVIDUAL GRANTS 2011/12
ETHNICITY/DISABILITY MONITORING
We would be grateful if you would complete this form indicating which of the following options best applies to you.
This form helps the Foundation ensure it is receiving applications from all sections of the community. Information
you provide is for monitoring purposes only and is not used in the assessment of your application.
Family / Last
Name
I am:
First Name/s
Female
Male
Nationality
Date of Birth
I would describe my ethnic origin/heritage as (please tick):
Black, African heritage
Black, Caribbean heritage
Black, Other
Bangladeshi
Indian
Pakistani
Asian, Other
Mixed Race
White, European
White, UK heritage
White, Other
Any Other Ethnic Group – e.g. Turkish, Iranian etc
Prefer not to say
I am dyslexic
Yes
No
I have a disability other than
dyslexia
Yes
No
I am registered disabled
Yes
No
DATA PROTECTION ACT
I agree that the information given on this form may be processed by the Foundation in accordance with
the Data Protection Act, in particular, for the purpose of equal opportunities monitoring. I agree to the
storage of this information on manual and computerised files and understand that this information is
used for monitoring purposes only.
Signature
Date