Assessment Only Application Form SCITT PGCE & QTS

Applicant Details

Title (PLEASE TICK APPROPRIATE BOX)*

Surname / Family name (BLOCK CAPITALS)*

First name (s)*

Previous surname / Family name, if changed

Address*

Telephone number*

Email Address:*

Date of birth:*

Gender: Male (M) Female (F) Do not wish to declare (N)*

M
F
N

Do you have any criminal convictions or are you currently on bail or being investigated by the police?*

Yes
No

Nationality:*

Country of birth:*

Country of permanent residence*

Do you need a visa to live in the UK?*

Yes
No

If yes, please provide your passport number:

For applicants not born in the UK:

Date of first entry to the UK

Date of most recent entry to the UK (excluding holidays)

Have you been granted Indefinite Leave to Enter/Remain in UK

Yes
No

If you are a non-British EU National who is not living in the UK, will you have been resident in the EU for 3 years prior to the 1st of September of the year in which the AO period begins?

Yes
No

Do you have any special needs including dyslexia or medical condition?

Yes
No

Do you have any criminal convictions or are you currently on bail or being investigated by The Police?

Yes
No

Failure to disclose criminal convictions may lead to offers of assessment being withdrawn. It is not possible to accept applicants who have previously failed a QTS assessment or withdrawn from a QTS programme unless there are exceptional circumstances. If this applies to you, please provide a written explanation and also provide the contact details of your previous training provider.

Please give details of any additional needs including dyslexia and/or any medical conditions?*

Please give details of any additional needs including dyslexia and/or any medical conditions?

Please give details of any reasonable adjustments you need us to make during the interview or assessment period*

Please give details of any reasonable adjustments you need us to make during the interview or assessment period

Previous QTS Assessment

Have you failed or withdrawn from a QTS course?*

Yes
No

If yes, give the name of the previous course and provider

If yes, please give details of circumstances

Studies from*

Studies to*

Qualifications

Degrees or equivalent

Name of Institution*

Class*

Title of course*

From*

To*

GCSEs or equivalent qualifications

Subject*

Grade*

Awarding Body*

Date of award*

Subject

Grade

Awarding Body

Date of award

Subject

Grade

Awarding Body

Date of award

Subject

Grade

Awarding Body

Date of award

Subject

Grade

Awarding Body

Date of award

Skills Tests

Please let us know if you have already passed your skills tests

Subject

Date passed

Subject

Date passed

Subject

Date passed

Subject

Date passed

Subject

Date passed

Other qualifications

Subject

Date passed

Subject

Date passed

Subject

Date passed

Subject

Date passed

Subject

Date passed

Education

Date from*

Date to*

Name of school*

Date from

Date to

Name of school

Date from

Date to

Name of school

Date from

Date to

Name of school

Date from

Date to

Name of school

Employment

Please give details of previous employment. Please start with your current employment.

Date from*

Date to*

Name of employing institution*

Street Address*

Town*

Postcode*

Role*

Age range taught (if applicable)*

Date from

Date to

Name of employing institution

Street Address

Town

Postcode

Role

Age range taught (if applicable)

Date from

Date to

Name of employing institution

Street Address

Town

Postcode

Role

Age range taught (if applicable)

Date from

Date to

Name of employing institution

Street Address

Town

Postcode

Role

Age range taught (if applicable)

Date from

Date to

Name of employing institution

Street Address

Town

Postcode

Role

Age range taught (if applicable)

Full employment history must be given and any gaps explained. NB You must have been employed as an unqualified teacher for approximately 2 years in 2 different schools in at least 2 key stages (these do not need to be consecutive).

Please confirm the following:

I have taught in 2 different schools*

Yes

I confirm that I have taught across the age range for which I am applying to be assessed*

3-7
5-11
7-14
11-16
11-18

I have taught for 2 years on the unqualified teachers’ pay scale or equivalent*

Yes

I have taught all subjects in the National Curriculum for primary schools*

Yes

Personal Statement

Please describe your reasons for wanting to gain Qualified Teacher Status. You should make reference to your personal strengths, qualities, skills and previous experience in teaching.*

Please supply the details of 2 referees.

Both referees should be educational professionals (one of which must be someone who has observed you teaching). You must have references from 2 different schools who have employed you.

First Referee

Name*

Post held*

School Name*

Address*

Postcode*

Telephone no*

Relationship to the candidate*

Email*

Second Referee

Name

Post held

School Name

Address

Postcode

Telephone no

Relationship to the candidate

Email

Data Protection Act, 1998: The information that you have supplied will be processed and held on computer. The data may be processed for the purpose of compiling statistics, and passed to the Higher Education Statistical Agency and the Higher Education Funding Council for England. By signing and returning this application form you will be deemed to be giving your consent to the processing of data contained within it and the use of that data for the lawful purposes approved for the institutions to which it is supplied.

Declaration

I confirm that the information I have given on this form is true, complete and accurate and no information requested, or other material information, has been omitted.

Applicant’s signature*

(an electronic signature is acceptable)

Date

'Putting Children First, Training Excellent Teachers'

'Putting Children First, Training Excellent Teachers'