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Personal Details

First name

Last name


Date of Birth

Address 1

Address 2







Country of Birth

Country of Residence

Keele Registration no.

Qualifications & Employment

Academic and professional qualifications.

Please include academic institution, degree classification and year attended. NB You are required to send a copy of your degree certificate with your application form.

Details of professional registration body and personal registration number:

Current Employment

Please include your job title/role, employer's name, address and date employment started. NB Please send your employer's reference with your application form.


Course & Course No

Start Date

End Date

Briefly state the reason for choosing module/s

I hereby apply for admission to study at Keele University for the course set out and confirm that the information provided is correct to the best of my knowledge.

Upload copy of degree

Equal Opportunities Monitoring

Please help us make our equal opportunities policy effective by ticking the boxes applicable to you.


11 White-British12 White-Irish13 White-Scottish14 Irish Traveller19 Other White Background21 Black or Black British-Caribbean22 Black or Black British-African29 Other Black background31 Asian or Asian British-Indian32 Asian or Asian British-Pakistani33 Asian or Asian British-Bangladeshi34 Chinese Ethnic background39 Other Asian background41 Mixed-White and Black Caribbean42 Mixed-White and Black African43 Mixed-White and Asian49 Other Mixed background80 Other Ethnic background90 Not Known98 Information refused


The University welcomes applications from people with disabilities and considers them on the same academic grounds as those from other candidates. If you indicate on this form that you have a disability, and if we make you an offer of a place, we will then inform our Disability Services department who will contact you to discuss your support needs.

00 No known disability

If you have a disability, please indicate those which are applicable to you.

01 Dyslexia02 Blind/ partially sighted03 Deaf/ hearing impaired04 Wheelchair user/ mobility difficulties05 Personal care support06 Mental health difficulties07 An unseen disability, eg. diabetes, epilepsy, asthma10 Autistic Spectrum Disorder/Asperger's Syndrome08 Multiple disabilities09 A disability not listed above

Criminal Convictions

If you have a relevant criminal conviction that is not spent, please tick the box; otherwise leave it blank. If you tick the box you will not be automatically excluded from the application process.

99 I have a criminal conviction

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