FDIS Application Form

Please write clearly using block letters in black or blue ink. Continue on additional sheets if necessary.

Please send completed application form and required documents to Admissions Office, Jamia Al-Karam, Eaton
Hall, Retford, Nottinghamshire, DN22 0PR.

Checklist of documents to send with the application form:

1. Completed application form

2. Details of academic and employment history
3. Personal statement
4. Two recent passport sized photographs
5. Copy of identity section of valid passport
6. Copy of full birth certificate showing names of both parents
7. Two written
Two references (one from
references (oneImam
fromor
theTeacher
Imam orofTeacher
Masjid attended)
of Mosque attended)

Section A – Personal Details

Surname (Family Name): ……………………………………………………………………………………..

Forename(s): …………………………………………………………………………………………………...
Date of Birth: ………………………………..…… Age: …………………… Gender: male / female [circle]
Place of Birth: ……………………………………………………. Nationality: ……………………………..
Address: ………………………………………………………………………………………………………..
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…………………………………………………………………………… Post Code: ………………………..
Home Telephone: …………………………………………. Mobile: ………………………………………..
Email: …………………………………………………………………………………………………………..

Father’s Full Name: …………………………………………………………………………………………...

Father’s Occupation: …………………………………………………………………………………………..
Father’s Telephone: …………………………………………....................................................................

Mother’s Full Name: …………………………………………………………………………………………..

Mother’s Occupation: …………………………………………………………………………………………
Mother’s Telephone: …………………………………………………………………………………………..
Section B – Academic History (from and including GCSE)

Please give details of your present/most recent institution, as well as previous institutions attended:

Institution From mm/yyyy to mm/yyyy

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Please give details of your qualifications gained:

Qualification (e.g.
Subject Grade Year Institution
GCSE, A Level, BA)
Section C – Work History

Please give details of your full employment history or voluntary work undertaken:

From To
Organisation Job/Role Paid/Voluntary
mm/yyyy mm/yyyy

Section D – Other Experience

Please give details of other experiences that you consider relevant to your application:

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Section E – Personal Statement

Please write your personal statement here, continue on additional sheet if necessary:

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Section F – Further Information

Do you have any disability, health condition or dietary requirement that we should be aware of:

Please tick: Yes No If yes, please give details:

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Do you have any criminal convictions or reprimands, or have you ever been charged with an offence:

Please tick: Yes No If yes, please give details:

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Are you or have you been a member, follower or supporter of any organisation or group, whether
religious, political or otherwise?

Please tick: Yes No If yes, please give details:

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How would you describe your cultural and ethnic origin?

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Please indicate if you speak any other languages aside English, and the level (written, spoken):

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Section G – Referee Details

Please
Please ensure your references
written references are sent
are sent along along
with yourwith your application
application as soon asaspossible.
soon as possible.

Full Name of Referee 1: ……………………………………………………………………………………..

Organisation …………………………………………………………………………………………………...
Position: ………………………………………………………………………………..………………………
Address: ………………………………………………………………………………………………………..
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Telephone: …………………………………………. Email: ………………………………………………..
Known to applicant as: ………………………………………………………………………………………..
Any relation to applicant: ……………………………………………………………………………………..

Full Name of Referee 2: ……………………………………………………………………………………..

Organisation …………………………………………………………………………………………………...
Position: ………………………………………………………………………………..………………………
Address: ………………………………………………………………………………………………………..
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Telephone: …………………………………………. Email: ………………………………………………..
Known to applicant as: ………………………………………………………………………………………..
Any relation to applicant: ……………………………………………………………………………………..

Section H – Declaration

I declare that the information given on this form is correct. I also agree that if admitted to Jamia Al-
Karam, I will abide by all its terms, conditions and regulations.

I acknowledge that all fees are non-refundable and that Jamia Al-Karam reserves the right to terminate
my enrolment at Jamia Al-Karam for any reason it may see fit without notice. I understand I must meet
the standard expected of me in conduct and character as well as in academic studies and within the
residential environment and the institution community as a whole.

Signed by Applicant: …………………………………………………………… Date: ……………………

Signed by Parent/Guardian: ………………………………………………….. Date: ……………………...

Name: ………………………………………………………………………… Relation: ……………………