Bethlehem Moravian College

APPLICATION FOR BACHELOR OF EDUCATION ADVANCE STANDING PROGRAMME

INSTRUCTIONS: Complete this form with a black ink pen. Write in BLOCK CAPITALS.

SECTION I – PERSONAL DATA

1. Name

Title Surname First Name Middle Name(s)

2. a) Former Name (if applicable)

Title Surname First Name Middle Name(s)

3. a) Permanent Address: 4. Mailing Address (if different from 3)

______________________________________________ ________________________________________________

______________________________________________ _________________________________________________

______________________________________________ _________________________________________________

5. a) Which teacher training institution did you attend? b) Please state the following:

___________________________________________ Identification Number: ____________________________

___________________________________________ From (year) _______________ To (Year) ____________

6. Home Phone: _________________________ 7. Cell Phone:_______________________________

8. Work Phone:__________________________ 9. Fax Number:______________________________

10. Email Address:___________________________________________________________________________________

11. Gender: [ ] Female [ ] Male 12. Date of Birth (dd/mm/yyyy) ______/_____/________

13. Marital Status: [ ] Single [ ] Married 14. Religion/Denomination:____________________________

15. Emergency Contact Information:

Title Surname First Name Middle Initial Relationship to Applicant

SECTION II

16. Specify the Programme you wish to pursue.

Bachelor in Education

Early Childhood Education

Primary Education

History and Social Studies

Computer Science

Business Studies

Office Systems and Administration

English (Language/Literature/Spanish)

17. List educational institutions attended and any other programmes or courses you have completed,

which you wish to be used to satisfy the matriculation regulations of the entrance requirements.

Institution Name & Address

From

To

Type of Programme

Area/Specialization

Class of Award

18. List all subjects passed at CXC (CSEC) General Proficiency, CXC (CAPE) and GCE Ordinary and

Advanced Levels.

Examination Body Level Subjects Grade Date Awarded

SECTION III – EMPLOYMENT INFORMATION

19. List employment information starting with your current job.

a) Name of Employer:_______________________________________ Position:______________________________________________________ Address:_____________________________________________________ Tel.__________________________________________________________

b) Name of Employer: ____________________________________ Position:____________________________________________________ Address:___________________________________________________ Tel._________________________________________________________

SECTION IV – FINANCIAL RESOURCES

20. Source of Funding

[ ] Self [ ] Parent [ ] SLB [ ] Award (specify) __________________________________

[ ] Government (specify)_______________________________ [ ] Other (specify) __________________________

21. Will you be able to meet your financial obligation upon acceptance? [ ] Yes [ ] No

SECTION V – REFEREE INFORMATION

22. Give the names and addresses of two (2) referees, one of whom should preferably be from the last

school or college you attended, or last place of employment.

a) Name of Referee:_________________________________________ Organization:________________________________________________ Position:_____________________________________________________ Address:____________________________________________________ _______________________________________________________________ Tel.___________________________________________________________

b) Name of Referee: ______________________________________ Organization:______________________________________________ Position:___________________________________________________ Address:___________________________________________________ _____________________________________________________________ Tel._________________________________________________________

SECTION VI –BRIEF ESSAY

23. Write a brief essay indicating the reason for your choice of programme and your choice of this institution.

SECTION VII – DECLARATION

24. I hereby certify that I have read and understood the instructions necessary for completing this application and that all statements made are true and complete. I understand that otherwise my admission to or registration at BMC may be revoked. ________________________ ____________________ Signature of Applicant Date (dd/mm/yyyy)

25. This application is made with my consent and I intend to provide such fees as may be payable to BMC. ______________________________ ____________________ Signature of Parent/Gaurdian Date (dd/mm/yyyy)

FOR OFFICIAL USE BY BMC

Documents Received: Application Fee – Receipt no.______________ Photographs Birth Certificate Marriage Certificate Deed Poll Transcripts CXC?GCE Certificates References Other(specify):_________________________

BMC ASSESSMENT Qualified Not qualified Pending Results Refer for decision re matriculation

________________________ ____________________ Authorized Signature Date (dd/mm/yyyy)