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International College of Oriental Medicine

I would like to apply for Autumn 2023 intake *

Full-timePart-time

Surname *

First Name *

Preferred Name

Name on qualifications (if different)

I identify my gender as: *
ManWoman
Other

Date of Birth * - DD/MM/YYYY

Age *

Nationality *

Please tick this box if you are NOT a British Citizen or a Citizen of a European Community member country:
I am NOT a British Citizen or a Citizen of a European Community member country
If you will be residing in the UK while on this course, please give details of your arrangements made with the Home Office regarding your residency in Britain.

Profession *

Email Address *

Telephone number *
Home
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Home Address (non term) *

Contact Address (during term if known)

Where did you first hear about the college (please specify, e.g. Facebook, Twitter, Google search, Word of Mouth, etc.) ? *

Do you have any previous study / experience of Acupuncture or other holistic therapies? *
Please provide details below including start / end dates

Professional / Work Experience to date *
Please make a numbered list providing accurate details for each position held, including start/end date, company name and main tasks.
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Formal Education (Dates of study and place of study) *

Qualifications. Please make a detailed list (i.e. GCSEs and 'A' levels, NVQ or equivalent and degree or further education qualifications) including the name, the date and the grade achieved *
Please note that original certificates will need to be seen at interview.
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State your reason for wanting to study Acupuncture and your suitability to become a practitioner *
Please write extensively

Please provide a Reference explaining their relationship to you Must be a professional or academic referee *
Name *

Address *

Email *

Telephone Number *

In what capacity is this person known to you? *

Please write a statement declaring your health status *
Include information about any health issue or disability that may hinder or prevent your learning so that we can determine any support that you may need.

Will you be applying for exemptions in any subject(s)? *
YesNo
If yes, please indicate which subject(s):

CRIMINAL OFFENCE DECLARATION *
Have you been convicted of, cautioned for or charged with any criminal offence? Conviction includes being put on probation or being given an absolute or conditional discharge or being bound over or being given formal caution. This includes convictions which would normally be regarded as spent under the Rehabilitation of Offenders Act 1974.

YESNO

If YES, please give full information about the nature of the offence, the date of conviction or caution and the sentence.
Details:

DATA PROTECTION ACT 2018
The information which you give will be used for the following purposes: to enable ICOM to create a computer and paper record of your application; to enable the application to be processed; to enable the institution to compile statistics, or to assist other organisations to do so, provided that no statistical information that would identify you as an individual will be published. The information will be kept securely, and will be kept no longer than necessary.

I declare, to the best of my knowledge and belief, that the information I have given in this application is true. I am aware that if I am offered an unconditional place on the course I will be required to complete an online Criminal Records Bureau (CRB) application. I understand that I must submit the necessary documents as soon as possible, when requested, in order to participate in clinic practice learning. I understand that a record of a criminal offence for which I have been convicted, cautioned or charged may prevent me from being permitted to complete the course or subsequently being eligible for state registration.

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