Carlow
College
FOR OFFICIAL USE ONLY:
Date Received: _____________ Photos (1): Y / N
COURSE CODE ______________
Fee Due: € __________
Payment Received: Y / N
APPLICATION FORM - ACCS
SECTION 1 PROGRAMME/SUBJECT DETAILS
BLOCK CAPITALS
PLEASE INDICATE BELOW THE PROGRAMME YOU INTEND TO FOLLOW:
B.A. in Humanities*
(PC402)
B.A. (Hons) in Humanities*
(PC410)
B.A. (Hons) in English & History*
(PC411)
B.A. (Hons) in Citizenship & Community Studies
(PC405)
B.A. in Applied Social Studies in Social Care
(PC404)
STAGE ONE
Applicants may choose a maximum of 30 credits worth of modules:
1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
4. ______________________________________________________________________
Do you wish to sit examinations (QQI accredited) for the above subjects?
Yes
No
*Please note that BA/BA (Hons) classes attend the same lectures but have separate continuous
assessment and exam arrangements. It is the student’s responsibility to ensure that they follow the
guidelines set out for assessments and exams in relation to the programme level for which they have
registered. Course credits (honours/ordinary) cannot be amalgamated.
SECTION 2 PERSONAL DETAILS
SURNAME: _________________________
BLOCK CAPITALS
FORENAME(S):________________________
ADDRESS:_____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
DATE OF BIRTH: ______/_______/________ PPS NUMBER: __________________________
TEL: Home ____________________________ Mobile__________________________________
Please print clearly; i.e. use lower case
E-MAIL:_____________________________________________
or capital letters where applicable.
SECTION 3 EDUCATIONAL DETAILS
BLOCK CAPITALS
EDUCATION - SECOND LEVEL
Name & Address of School
Exams Taken e.g. Leaving Cert.,
Year Undertaken
Junior Cert.
1.
2.
EDUCATION – PLC/FETAC/OTHER
Name & Address of College
Date Attended
Course Title
Awarding Body
e.g. FETAC, BTEC etc.
1.
2.
EDUCATION - THIRD LEVEL
Name & Address of College
Date Attended
Course Title
Awarding Body
e.g. HETAC etc.
1.
2.
ANY OTHER RELEVANT QUALIFICATION
Qualification obtained e.g. First Aid, TCI etc.
Date
SECTION 4 EMPLOYMENT DETAILS
Awarding Body
BLOCK CAPITALS
1. Current
NAME & ADDRESS OF EMPLOYER:
CONTACT NAME:
FROM:
DUTIES:
TO:
VOLUNTARY
PAID
VOLUNTARY
PAID
2. Previous
NAME & ADDRESS OF EMPLOYER:
CONTACT NAME:
FROM:
DUTIES:
TO:
SECTION 5 STATEMENT OF PURPOSE
PLEASE COMPLETE
Please write a short statement of purpose indicating your reasons for undertaking your
chosen course of study.
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SECTION 6 SPECIFIC TO THE PROGRAMME
PLEASE TICK
Have you any disabilities* which might need special requirements?
Wheelchair User, Hearing/Visual Impairments?
Yes _____
Example Dyslexia,
No _____
If yes, give details/specify: _____________________________________
*If you are a student with additional educational needs you are encouraged to contact the Academic
Resource Office at 059 9153223, to discuss your situation in a confidential and friendly manner.
SECTION 7 REFEREES
BLOCK CAPITALS
All applicants are required to obtain at least TWO references as follows:
Applied Social Studies/Citizenship and Community Studies advanced entry
applicants: must obtain One Social Care Referee AND One Academic Referee. (where
possible)
Humanities/English and History advanced entry applicants: must nominate One
General Character Referee AND One Academic Referee.
N.B.
THE REFEREE CANNOT
(a)
be related to you
(b)
be a babysitting reference
Please tick box to indicate status of referee e.g. general character, social care or
academic.
REFEREE No 1:
Name:
Gen. Char
Social Care
Academic
_________________________________________________________________
Address (in full): _________________________________________________________________
_______________________________________________________________________
REFEREE No 2:
Name:
Gen. Char
Social Care
Academic
_________________________________________________________________
Address (in full): _________________________________________________________________
_______________________________________________________________________
REFEREE No 3:
Name:
Gen. Char
Social Care
Academic
_________________________________________________________________
Address (in full): _________________________________________________________________
_______________________________________________________________________
SECTION 8 ADMINISTRATIVE DETAILS
PLEASE COMPLETE
The following documentation should accompany this application form:
1.
2.
ONE passport photograph (signed on the back)
Copies of all certificates/documentation in relation to education/training achieved.
I acknowledge that the particulars given on this form are in all respects true.
SIGNATURE: _______________________________
DATE: _________________
This form should be completed and returned to ACCS Administrator
Office, Carlow College, College Street, Carlow at your earliest
convenience.
NOTE:
INCOMPLETE OR LATE APPLICATION FORMS CANNOT BE PROCESSED.