1) Have you previously studied at NUI Galway?Yes No If you selected "yes" please specify what year you were registered:2) Surname*:3) First Name(s)*:4) Full Name as stated on Birth Certificate5) Gender*:Male Female 6) Date of Birth*:Format DD/MM/YYYY7) PPS Number*:8) Nationality*:9) Email Address*: (PLEASE ENSURE YOU PROVIDE A VALID EMAIL ADDRESS AS ANY FURTHER CORRESPONDENCE FROM NUI GALWAY PRIOR TO REGISTRATION WILL BE EMAILED TO THE EMAIL ADDRESS YOU PROVIDE)10) Address for Correspondence:Address 1Address 2Address 3Address 4County:11) Telephone (Landline):12) Telephone (Mobile)*:FORMAT 086600101213) Payment of fees (please tick):If your sponsor is funding your participation on this course, please enclose a completed Sponsorship Letter with your application.Personal Funds Sponsorship Letter (e.g. employer, voluntary body etc.) Other (please specify) If you selected "other" please specify:14) Particular student needs:Access (wheelchair etc.) Learning Supports (Dyslexia etc.) Other (please specify) If you selected "other" please specify:15) Qualifications:Course 1 Title of course/Qualification taken:Name of Institution attended:Years of Study From/ToAward result achieved:Course 2 Title of course/Qualification taken:Name of Institution attended:Years of Study From/ToAward result achieved:Course 3 Title of course/Qualification taken:Name of Institution attended:Years of Study From/ToAward result achieved:16) Name and Address of Previous Employers (past 10 years):Employer 1 Name:Address:Position Held:From - to:Employer 2 Name:Address:Position Held:From - to:Employer 3 Name:Address:Position Held:From - to:17) Are you currently engaged on any other course, if so , please state the course title, duration and organisation you are studying with:18) Outline how this course would be of benefit to you in your employment:19) Give a brief statement of your reasons for applying for this course:
Pauline DillonProgramme AdministratorCertificate / Diploma in Employee Assistance and Social SupportOpen Learning CentreBallard HouseWestsideGalwayor e-mailed to email@example.com Please ensure the supporting documents are sent as soon as possible after submitting your online application. Please check that you have answered all questions. When completed, please press "submit" to send your application, you will then be sent an acknowledgment, so you will know it was successfully submitted. Best of luck with your application.