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Galway-Mayo Institute of Technology (GMIT) Access Programme 2015/2016

Application Form

Completed application forms (including all documentary evidence) should be returned to:

Dr. Carina Ginty, Schools Liaison Officer, GMIT, Dublin Road, Galway by 1 st May 2015

Section 1

General Information

(Please give your name as it appears on the CAO form)

CAO Number: _______________________________________

Surname: _______________________________________

First Name: _______________________________________

Date of Birth: _______________________________________

Gender: _______________________________________

Country of birth: _______________________________________

Nationality: _______________________________________

Home Address: _______________________________________

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Home phone no. _______________________________________ (must be filled in)

Mobile phone no. ________________________________________

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Correspondence Address: __________________________________

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Second Level Education

Second Level Attendance

Dates Attended

School(s) Attended From To

Second Level Examinations

Junior Certificate Year Leaving Certificate Year 2015Subject Level of Exam Grade/Mark Subject LevelExample: English Ordinary B Irish Higher

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CAO Course Choices: 2015 CAO No.

(Please give the CAO course code and the course title of each GMIT course for which you have applied on your CAO form. Give your preference for each course as it appears on your CAO application).

CAO Course Code GMIT Course title Preference (as on CAO form)

Personal Statement

Please provide a two hundred word statement indicating why you wish to pursue a third level programme of study at GMIT

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Interests/Hobbies

Describe briefly interests and hobbies that you enjoy in your spare time

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Section 2

Galway-Mayo Institute of Technology (GMIT)

Access Programme 2014/2015

Confidential Information

(The following Parts 1 – 7 should be completed by parent(s) or guardian)

The information provided will be used for the sole purpose of selecting students for the GMIT Access Programme and will not be disclosed to any third party under any circumstances.

PART 1 – Family details

Please list all family members, including those not currently living in the family home

Surname, First Name

Date of birth

Relationship to applicant

Is this person currently living in the family home? Please indicate (Yes/No)

Highest level of education achieved to date*

Current/most recent occupation or current place of study

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*Level of education i.e. Primary education, Group/Inter/Junior Certificate, Leaving Certificate, PLC, Adult Education, Certificate, Diploma, Degree, Masters degree etc

PART 2 – Place of residence

(Please tick the appropriate box)

Home owner Private rented accommodation

Local Authority tenant purchase scheme

Local Authority rented flat

Local Authority rented housing Other non-permanent accommodation (please provide details)

PART 3 – Family status

(Please tick the appropriate box)

Married SingleCo-habiting SeparatedWidowed DivorcedUnaccompanied adult Unaccompanied minorOther (please specify)

PART 4 – Medical card

(Please tick appropriate box)

YES NODo you have a full medical card?Do you have a GP only

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medical card?If yes, please give your medical card numberExpiry date of medical card

PART 5 – Income from paid employment (including self-employment)

Estimated total income for the year ended 31st December 2014

Father Mother Guardian Documents required

Occupation N/A

Income from employment (e.g. PAYE salary, wages, fees etc)

P60 and P21

Income from pension (from former employer or pension scheme)

P60 and P21

Income from self-employment P60 and P21

Income from land: profits from farming activities

Notice of assessment and accounts

PART 6: Income from other sources



Rental income (from property or land)

Relevant documentary evidence

Maintenance agreements Relevant documentary evidence

Separation/Divorce agreements Relevant 7

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documentary evidence

Other income (please specify) Relevant documentary evidence

PART 7 : Income from the Department of Social and Family Affairs (DSFA)



DSFA – Unemployment benefit P21 and Social Welfare Statement

DSFA – Unemployment assistance (short term)

P21 and Social Welfare Statement

DSFA – Unemployment assistance (long term)


DSFA – One Parent Family payment


DSFA – Pension Payment (please specify)


DSFA – Family Income Supplement


DSFA – Disability Benefit P21 and

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Social Welfare Statement

DSFA – Disability Allowance P21 and Social Welfare Statement

Other DSFA payment (please specify)


Declaration

(The declaration must be signed by both the applicant and his/her parent/guardian)

I certify that the information supplied in this application form is correct and complete.

Signature of applicant: __________________________________________

Date: __________________________________________

Signature of parent/guardian: ____________________________________

Date: __________________________________________

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Section 3

Galway-Mayo Institute of Technology (GMIT)

Access Programme 2014/2015

Referee’s Report

This section is to be completed by the School Principal/Guidance Counsellor or Year head. The completed form should be returned by 1st May 2015 to: Dr. Carina Ginty, Schools Liaison Officer, GMIT, Dublin Rd., Galway

Name of applicant: _____________________________________________________

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School attended: _____________________________________________________

Leaving Certificate Performance 2015

I predict that the applicant’s performance in the Leaving Certificate examination will be as follows:

Subject Level of Exam (Higher/Ordinary)

Predicted Grade

Academic qualities and school performance

I rate the applicant’s potential as follows:

(Please tick the appropriate box and include a further comment where necessary)

Qualities/abilities Very Good

Above average

Average Below Average

Poor

Motivation

Comment

Determination/staying powerComment

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Past record of attendanceComment

Level of literacy

Comment

Level of numeracy

Comment

Adaptability to new situationsComment

Potential to cope with new situationsComment

Additional comments

1. What particular supports do you think the applicant would require in order to ensure success in college?

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2. Is there any other information that would support the student’s application?

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Signed: __________________________________________________

Position held: _____________________________________________

Date: ____________________________________________________

Thank you for completing this report

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