CPD Pharmacist Professional Programme - credit only Application Form

Programme

Start Term

Title

First Name

Last Name

Mobile Phone

Date of Birth (dd/mm/yy)

Street Address

City

Postcode

What is your highest qualification?

Upload your Qualification

What is your GPhC registration number?

What is the name of your current employer?

About You

Your Nationality

Your Country of Birth

Your Country of Permanent Residence

Your Country of Permanent Residence is the country where you normally reside and have citizen status, or hold a visa without restrictions.

Do you have dual nationality?

YesNo

Do you have a current Passport?

YesNo

Passport Number

Name, as it appears on your Passport

Your Place of Birth (if shown on your Passport)

Country of Birth (as detailed on your Passport)

Nationality (as detailed on your Passport)

Passport Place/ Department of Issue

Passport Issue Date

Passport Expiry Date

Upload a copy of your Passport information page:

Please note: European students who do not have a passport but do have a European ID card should upload copies of the ID card in this section

Please confirm your secondary nationality

Do you have a current Passport for your dual nationality?

YesNo

Passport Number

Name, as it appears on your Passport

Your Place of Birth (if shown on your Passport)

Country of Birth (as detailed on your Passport)

Passport Place/ Department of Issue

Passport Issue Date

Passport Expiry Date

Upload a copy of the information page of your second Passport:

The University is required to check the Right to Study in the UK for all students. Please confirm your immigration permission that enables you to study in the UK (for example, Tier 2 visa, Dependant Visa etc):

Please upload a copy of your Immigration Permission document:

The University collects information from all applicants on key characteristics which are related to equal opportunities. The information requested in this section will not affect the academic assessment of your application.

Gender

Ethnic Origin

If you have a disability, mental health condition or specific learning difficulty, such as one of those mentioned below, it’s a good idea to inform us, to discuss what support you might need as early as possible. Doing so means we can start to put the right support in place for you.

If you have any questions or concerns please contact our disability team in the Student Services Centre.

Please indicate if you have a disability or long-standing health condition

The University requires you to state whether you have a relevant criminal conviction. Please select ‘Yes’ box if you have a relevant criminal conviction you need to declare or leave the box blank if you do not. If you select ‘Yes’ you may be required to provide details of any convictions.

The University has a duty of care to ensure the safety of the community at all times. All applicants are required to state whether or not they have a relevant criminal conviction. Failure to disclose a criminal conviction on each application to the University may affect either acceptance on to a programme or continuation of studies on it.

Relevant criminal convictions are currently defined as:

Any kind of violence including (but not limited to) threatening behaviour, offences concerning the intention to harm or offences which resulted in actual bodily harm
Offences listed in the Sex Offenders Act 2013
The unlawful supply of controlled drugs or substances where the conviction concerns commercial drug dealing or trafficking
Offences involving firearms
Offences involving arson
Offences listed in the Terrorism Act 2006

Unless the nature of your course of study* requires us to ask questions about your entire criminal record, you do not have to declare a conviction that is classed as spent under the terms of the Rehabilitation of Offenders Act 1974. You may wish to seek advice from Unlock who can provide specific advice in relation to applications to Higher Education.

* Courses include those in teaching, health and social work or courses involving work with children or vulnerable adults.

Do you have any criminal convictions you are required to declare?

Are you a member of University (or associated institutes) staff?

The University defines near relatives as "husbands or wives or children of members of staff”, however the University also considers that partners, parents, uncles, aunts, nieces, nephews, those considered as next of kin and grandchildren of members of staff may also be regarded as near relatives. The University will not unreasonably deny access to the University to any applicant on the basis of their relationship to another member of staff or their own position as a member of staff. However, the University has a responsibility to ensure relevant controls are in place so that the applicant will not receive unfair advantage during their time at UEA as a consequence of this relationship or their staff position and that these conditions will be monitored by a named individual.

Are you related to a member of University staff (or associated institutes) or in a close relationship e.g. partner or next of kin?

Relative's first name

Relative's last name

Relative's email address

What is their job role at UEA?

Declaration

I confirm that the information given on this form is true, complete and accurate, no information requested or other material information has been omitted, and that I have completed the application myself. I agree that I have read the accompanying information on the section pages. I undertake to be bound by the terms set out in the application form and application notes and I give consent to the UEA to process the data I have supplied. I accept that if I do not fully comply with these requirements the University will have the right to cancel any application and that I shall have no claim against the University with regard to this.

How information about you will be used:

The UEA is a registered data controller and we are required to process the personal data we collect from applicants in accordance with UK Data Protection laws.

By supplying your personal information in this application form, you agree to the following:

The University will collect your data, or data you are providing on behalf of a data subject (e.g. agents acting on behalf of an applicant) for the purposes of processing the application in accordance to our privacy notice. Data will be retained in accordance with our records retention policy.

The University may, when necessary, securely share a limited amount of personal data with third parties in order to verify the information you have provided. These third parties may include:
UK Visas and Immigration, regarding statutory information required for a UK visa
English Language test providers, to verify results
UK National Recognition Information Centre (NARIC)
Your nominated referees
Your previous institution, to verify grades
NHS Bursaries Agency and Local NHS Trusts

For further information on your how we use your information, and your rights under the Act, please read information on data protection or contact the University’s Information Policy and Compliance Managers: dataprotection@uea.ac.uk 01603 59 2431/3523.

Please read our Admissions Policy for additional information.

Declaration