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COLLEGE OF OSTEOPATHS
Postgraduate Application Form
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Please note: Fields marked * are mandatory
Year wishing to start programme Please indicate if you are interested in either the 5 year programme or the fast track option 5 year programme Fast-track option
Please Tick Naturopathy Advanced Diploma Postgraduate Certificate (PG Cert) Masters

Surname* Title
Forename(s)*
Home Address*
Postcode* Email*
Home Telephone No. Mobile No.
Work Telephone No. Place of Birth
Nationality Date of Birth
Correspondence Address (if different from above)

Academic Background (Please give details, starting at the most recent, of all colleges and universities attended)
Dates
From - To
mm/yy mm/yy		 Institution attended &
Country		 Full time or part
time		 Qualification awarded and
subject		 Result &class/
grade etc

Professional Qualifications
Dates
From - To
mm/yy mm/yy		 Institution attended &
Country		 Full time or part
time		 Qualification awarded and
subject		 Result &class/
grade etc

EMPLOYMENT
Current Employment
Name and Address of Employer
Start Date
Position held and responsibilities
Previous employment and responsibilities
1. Name and Address of Employer
Start Date
End Date
Position Held and Responsibilities
Reasons for leaving
2. Name and Address of Employer
Start Date
End Date
Position Held and Responsibilities
Reasons for leaving
3. Name and Address of Employer
Start Date
End Date
Post ion Held and Responsibilities
Reasons for leaving
Further Information on Employment and Work Experience
(Please include any further information that you believe we will find useful in assessing your application.)
About Yourself
(Please write in this space any other information about yourself that you believe we will find useful in assessing your application.)

References. Please supply the names and addresses of two professional referees, not related to you, who have know you for at least three years.
Name
Address
Relationship
   
Name
Address
Relationship

Where did you hear about our programme of study?

EQUAL OPPORTUNITIES MONITORING

The College of Osteopaths is committed to Equal Opportunities, irrespective of age, background, colour, disability, domestic / family circumstance, gender, nationality, political belief, race, religious belief, sexual orientation, trade union or other external activity or other irrelevant distinction.

In order for us to monitor the implementation of our policy we require all applicants to complete and sign the form below. This information will be treated in the strictest of confidence and will be used only for statistical monitoring.
Date of Birth (DD/MM/YY) Sex
Ethnic Origin Asian Black Middle / Near Eastern Mixed Ethnic Group White
Other (please specify)

DISABILITY

If you are unsure whether you have a disability that will prevent you from practicing as an osteopath you should contact the General Osteopathic Council, 176 Tower Bridge Road, London SE1 3LU. Tel: 020 7357 6655 Website: www.osteopathy.org.uk
Are you aware of having any health problems?
If YES, would you please specify
Are you considered to have a disability?
If yes, please describe this disability?
If you are registered disabled, please enter you Disabled Person Number:
Do you consider yourself to suffer from Dyslexia?
Have you been assessed or received counseling for Dyslexia?
Declaration: I confirm that all the enclosed information is true to the best of my knowledge (Please tick box to confirm)
Date
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