FOR OFFICE USE ONLY
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Limerick School of Art & Design LIT
Clare Street
Limerick
Tel: +353-61-208871 Fax: +353-61-311496
Email: muriel.dinneen@lit.ie
Web: www.lit.ie
Date Received _______________
Offer: Yes
No
Request Qualifications:
Reserve List:
Signed Head of School/Department:
_______________________________
Date: __________________________
ART & DESIGN TEACHER EDUCATION APPLICATION
FORM FOR ACADEMIC YEAR 2012-2013
If you have ever been registered for a course
in LIT, please quote your Student/ID Number:
PERSONAL DETAILS – Please complete in block capitals
Surname:
Surname on Birth Certificate if different from above:
First Name(s):
Address:
Email:
Phone Number:
Mobile Number:
PPS Number:
Country of Birth:
Date of Birth:
Citizenship:
Gender:
Male
Female
THIRD LEVEL EDUCATION:
Names &
Addresses of
Institutions
Attended
Years of Study
From
To
Major Areas
of
Specialisation
Qualifications
WORK EXPERIENCE
Name of Employer:
Address of Employer:
Phone Number:
Position held by Applicant:
Dates of Employment:
Brief Description of Duties:
From:
To:
Award
Levels
(e.g. 1st
Class
Honours)
Name of Employer:
Address of Employer:
Phone Number:
Position held by Applicant:
Dates of Employment:
From:
To:
From:
To:
Brief Description of Duties:
Name of Employer:
Address of Employer:
Phone Number:
Position held by Applicant:
Dates of Employment:
Brief Description of Duties:
Please use additional sheets and include any time spent in schools or working alongside an Art
Teacher.
1. Have you previously applied to undertake the Art and Design Teacher Education course at
Limerick School of Art & Design:
Yes
No
If yes, state year(s) ____________________________________________________________
2. Please state how the Art and Design Teacher Education Course at Limerick School of Art &
Design came to your attention: - Newspaper, media, webpage, word of mouth, other (please
specify: ______________________________________________________________________
3. If you consider yourself to have a disability or significant health problem, please give details
below and attach medical documentation obtained within the last three years: Yes
No
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. Do you require special educational support: Yes
No
If yes, please specify ____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I certify that I have read and understood the contents overleaf and that the information I have
provided on this form is complete and accurate.
Signed: ________________________________
Date: _______________________
Please complete in BLOCK CAPITALS and send to:
Muriel Dinneen
School Administrator
Limerick School of Art & Design LIT
Clare Street
Limerick
to arrive no later than 5.00pm on the 2nd March 2012