APPLICATION FOR CIH DISTANCE
LEARNING COURSE YEAR 2 AND YEAR 3
Please complete the form and send it back to CIH Distance Learning by email, post or fax
(details given at the end of the form). If you require any help filling in this application form or would
like further information please contact us on Tel: 024 76 851789 Fax: 024 76 694209 Email:
dlc@cih.org.
Section 1 - Your details
Your surname
Home telephone number
Your first name(s)
Home address
Mr/Mrs/Miss/Ms/Dr
Designatory letters e.g. BA, CIHM
Country of Birth
Nationality
We will mainly communicate with you by email. Please confirm which email address you
would like us to use. (please write clearly)
Home:
Work:
Section 2 - Your employment details if changed from Year 1
Employer Name
Job title
Address (this is the address where your
course materials will be sent to unless you
indicate otherwise overleaf)
Date of commencement
Postcode
Telephone number
Is this the Head Office
Fax number
If no, please give the Head Office address below:
Which of the following categories would your employing organisation fall into (please give the full
details choosing from the list below):
Housing Association and RSLs
Rent Service
Local Authority
Government Agency
Private Organisation
Voluntary and Representative
Other (please specify)
Your course materials will be made available on Moodle website and prior to the start of
your course you will be sent more details.
APPLICATION FOR CIH DISTANCE
LEARNING COURSE YEAR 2 AND YEAR 3
Section 3 - Course details
Which course do you wish to apply for (please give the full title from the list below):
Level 4 Diploma Year 2
PDHSC Year 2
MSc Housing Studies - Year 2
MSc Housing Studies – Year 3
When do you want to start this course?
(NB. closing date for registration 28 September 2012 for Level 4, and
10 August 2012 for PDHSC/MSc)
September 2012
March 2013
Other (please specify)
Section 6 – Options MSc Housing Studies - Year 2 students
Choose one options from:
Housing with care and support
Planning and development
Customer & neighbourhood services
Section 7 - Method of payment
There are various ways you can apply for this course, depending on how you return the form to us.
Self financing students
Either
Return the form by email/fax and send a cheque payable to ‘Chartered Institute of Housing’ and a
copy of application form in the post (please note we will not be able to process your application form
until we have received your cheque)
Or
Return the form by email/fax and tick this box
if you wish to pay by credit card.
After you have sent back your form, please telephone us asap with your credit card
information on 024 7685 1789 - we accept Mastercard/Visa/Switch/Maestro.
Sponsored students
Either
Return the form by email, and send a letter of authority (this should include the name of the student,
the amount to be invoiced and the address for the invoice to be sent to) plus a copy of application
form in the post (please note we will not be able to process your application form until we have
received your letter of authority) or
Return the form by post completing the below declaration by employer or including a letter of
authority (this should include the name of the student, the amount to be invoiced and the address for
the invoice to be sent to).
APPLICATION FOR CIH DISTANCE
LEARNING COURSE YEAR 2 AND YEAR 3
Declaration by employer
I hereby declare that the course fees will be paid for this applicant upon receipt of an invoice. If you
are only paying part of the course, can you please state clearly what percentage this is.
Employer Name
Telephone number
Address for invoicing
Authorised by (signature)
Postcode
Authorised by (please print)
Section 13 - Declaration by applicant
I certify that the information given in this form is correct (please complete if faxing or posting this
application form).
I do/do not authorise CIH to pass on details of my progress on this course to my sponsor or
employer (please delete as appropriate)
Signature
Date
Please send your completed application form by e-mail, post or fax to:
Distance Learning Centre, Chartered Institute of Housing, Octavia House, Westwood Way,
Coventry, CV4 8JP.
Tel: 024 7685 1789
Fax: 024 7669 4209
Email: dlc@cih.org
If you do not receive confirmation of receipt of your application form within
two weeks of sending it please contact us.