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1. Contact Details

Title:

(Mr/Mrs/Ms etc.)

Address:

All correspondence with applicants will take place via email, therefore you must have an active email address.

2. Nationality & Residency

Maths for STEM Certificate 2019-20 Leading to:

QQI Maths for STEM Level 5 Special Purpose Award (5S2246)

Have you been ordinarily resident within the EU/EEA/Swiss Confederation for 2 out of the last 4 years?

Country of birth: Nationality:

Country of residence:

Email:

Home number: Mobile number:

Date of Birth: Age:

Surname: First Name:

F M Gender:

Yes No

Please attach a

passport size

photograph here

/ If no, please indicate when you became resident:

Month Year

Please enclose a copy of your birth cert or passport with your application

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3. Educational Qualifications

Please tick all that relate to you:

Please include a copy of results for your highest qualification with your application.

Please indicate the highest level of formal mathematics qualification you have achieved to date:

Qualification Level

(Please indicate Higher, Ordinary, or Foundation Level: If

‘other’ please indicate)

Grade achieved Year achieved

Junior / Intermediate Certificate

Mathematics

Leaving Certificate Mathematics

Leaving Certificate Applied

Mathematics

QQI/FETAC Mathematics Level 4

QQI/FETAC Mathematics Level 5

Other (Please specify)

Please indicate if there are any specific areas of mathematics which you find challenging.

Please include a copy of your mathematics results with your application.

Very Confident

Confident

Unsure

Lacking some confidence

Not confident at all

Please indicate your current level of confidence with regard to studying mathematics .

Primary

Junior Cert / Intermediate Cert

Leaving Cert or equivalent

Leaving Cert Applied

QQI Further Education Full Awards Please indicate QQI level(s): __________________

Further Education Module / Component Awards

Third Level / Higher education (e.g. diploma, degree, masters)

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5. Benefits & Allowances

4. Employment

Please give brief details of your current and previous employment(s):

6. Other

Please include any additional information which you feel is relevant to your application, including whether you require specific accommodation in relation to a disability, should you be invited to an interview.

Employer Start Date Finish Date Type of work

Are you in receipt of or are you dependent on someone who is receipt of :

Please tick if

applies to you.

Please provide further details.

Medical Card

Unemployment payment

Means-tested social pro-

tection payment

Family income supple-

ment payment

Jobs initiative or commu-

nity employment scheme

Participate in VTOS or

Youthreach

Other

Please provide proof of your entitlement to the above payment or medical card with your application.

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7. Personal statement

Please outline briefly why you would like to participate in the Maths for STEM course (Enclose an extra page if required).

8. Please sign all sections below

Student Data Protection Privacy Notice

The Maths for STEM Certificate is offered by the Further Education and Training Division of Limerick and Clare Edu-cation and Training Board, in partnership with the University of Limerick (UL). The University of Limerick, via the Mature Student Office, processes the applications for the course, conducts interviews, provides the HeadStart Maths refresher teaching, collects course fees, arranges teaching space in UL and communicates with the students during their time on the programme. Successful applicants become registered students of Limerick and Clare Edu-cation and Training Board and upon enrolment on the course students will be provided with Limerick and Clare Education and Training Board’s Student Privacy Notice. The University of Limerick (the University) must process your personal data (as set out above) in order to carry out its functions and manage its operations. The processing of this data is carried out in accordance with the General Data Protection Regulation (GDPR) / Data Protection Acts 1988-2018 and with the University's and Limerick and Clare Education and Training Board’s Data Protection Policies. The University and Limerick and Clare Education and Training Board are Data Controllers for personal data we process about you. The purpose of this Data Protection Privacy Notice is to explain how the University uses personal data we collect and hold about prospective students. This notice should be read in conjunction with the University’s Data Protec-tion Policy and Compliance Regulations (available at www.ul.ie/dataprotection). This notice extends to all your personal data as defined under Article 2(1) of the GDPR. The full, printable version of the University's Student Privacy Notice can be viewed at www.ul.ie/dataprotection. I confirm that I have read and understood the foregoing and the terms of the UL Student Privacy Notice.

Signed: _____________________________

Date: ______________________________

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Checklist

For your Maths for STEM Certificate application to be complete you must have:

1. All sections of this form completed

2. Documentary proof of Social Welfare payment , if applicable

3. Passport photo

4. Referee questionnaire completed

5. Certified photocopies of qualifications/courses completed

6. Certified photocopies of Birth Certificate or Passport

CLOSING DATE FOR APPLICATIONS:

FRIDAY 12th of July 2019

Completed applications should be sent to:

Mature Student Office

EM-019a, Main Building

University of Limerick

Limerick

Tel: 061-202735 Email: mso@ul.ie

Web: www.ul.ie/mso

This provision is supported by Limerick and Clare Education and Training Board and co-funded by the Irish Government and the European

Social Fund as part of the ESF Programme for Employability, Inclusion and Learning 2014 – 2020.

8. Please sign all sections below (contd.)

Applicant Declaration I confirm that the information provided in this application form is true and correct and that any supporting docu-mentation submitted with my application is genuine. I understand that the University of Limerick or Limerick and Clare Education and Training Board may cancel my application, withdraw or amend its offer or terminate my regis-tration on the programme if any aspect of my application is found to be falsified. Signed: _____________________________ Date: ______________________________

Consent to verify qualifications I hereby give my consent to the University of Limerick and Limerick and Clare Education and Training Board to make enquiries to all referenced institutions/bodies to satisfy itself that the information I have supplied is true and correct.

Signed: _____________________________ Date: ______________________________ This application is an expression of interest for the Maths for STEM Certificate for which you have applied. It does not constitute a contract between the applicant and the University of Limerick or Limerick and Clare Education and Training Board. It is practise to destroy all documents relating to unsuccessful applications at the end of the cur-rent academic year. Unsuccessful applicants who wish to receive feedback on their application are required to make a written request to the Mature Student Office, University of Limerick.