registrationformforprofessionaldevelopmentinofficial.docVIP

Registration form for Professional Development in Official Statistics Return to: MOffStat Administrator, Professional Training Team, Faculty of Social and Human Sciences, University of Southampton, Room 2037, Building 58, Southampton, SO17 1BJ, United Kingdom 1. Personal details Application Reference Number (Office use only) Title (Mr/Mrs/Miss/Ms/Dr) Surname or family name Forenames in full Male Female Date of birth in full (DD/MM/YYYY) Postal address Home address (if different) Postcode Postcode Valid from to E-mail Telephone Mobile Nationality (if dual give both) Country of birth Country of permanent residence 2. Proposed programme of study Please give the module(s) which you are applying for (in order of preference) STAT 4. STAT STAT 5. STAT 3. STAT 6. STAT  3. Additional needs Please tick the relevant box if you have any of the following disabilities / medical conditions which might require special arrangements or facilities 0 No disability 1 Learning difficulty (e.g. dyslexia) 2 Blind / partially sighted 3 Deaf / hearing impaired 4 Wheelchair user / mobility difficulties) 5 Autistic spectrum disorder 6 Mental health difficulties 7 Unseen disability e.g. diabetes 8 Multiple Disabilities 9 Disability / medical condition not listed above 10 Temporary disability Are you registered disabled? Yes No 4. Educational qualifications School/College Qualification Grade/Result Date Awarded  5. Higher education Please provide details of your academic qualifications. Please note that your current or most recent qualification should be detailed first.Institution Title of Qualification Main Subjects Studied Attendance (from–to) GPA/Degree Classification Language of Instruction Country of