Affix applicant’s photograph

Specialist Certificates in Health Promotion

Autumn 2007

Surname					First name/s:

________________________________________________________________________________

Full name as stated on birth certificate

________________________________________________________________________________

Ms	Mr	Mrs			Female		Male	

Date of birth
________________________________________________________________________________

Country of birth					Nationality
________________________________________________________________________________

Have you previously studied at NUI, Galway?		If so, state your Student ID number

________________________________________________________________________

Address for correspondence please ensure you are contactable at this address at all times
________________________________________________________________________

________________________________________________________________________

Telephone (mobile)		Telephone (daytime)		Email

________________________________________________________________________

Youthwork					Disability Services

Oral Health					Sexual Health 

Community Development Settings		Training and Education Centres

Previous Education	
Previous Educational Experience	

	

	

	

	

	Employment History commence with the most recent	

Application 
forms should
be returned
on or before:
27th July, 2007

		

		

		

		
To: Anne O’Grady,
Dept of Health Promotion,
Clinical Science Institute,
NUI, Galway,
Galway.		

		

		

		I acknowledge that the particulars given in relation to this application are in 
	all respects true.		Signature				Date

			___________________________________________

Please enclose
this itemised
documentation
to allow your
application be
processed.		
	o	Fully completed application form	
	o	Passport photograph	
	o	Non refundable application fee of €30 (money order or postal order, cash will not be accepted)	
	o	Copy of birth certificate	
	o	International Language Testing System (ILTS) certificate /TOFEL (for applicants whose first language is not English)	
	o	Personal statement (max 200 words) see below:

Personal Statement – your interest and suitability for participation in this Specialist Certificate training course:

Please submit a minimum of 200 words here outlining the following:
•	Your interest / motivation for participating in this training course;
•	How you feel you meet the selection criteria specified in relation to this course;
•	Why you feel you are a suitable participant for this course;
•	How you can apply your learning from this course to support your organisation / centre / service to be more health promoting;