Please complete in BLOCK CAPITAL LETTERS Please use additional paper if necessary SECTION A Note: The questions in Section A are for information purposes only 1. PERSONAL INFORMATION Surname Prefix Mr Mrs Ms Miss First Name Permanent Home Address Address for Correspondence (If different from permanent address) E-Mail: Phone No Mobile Phone No Gender Male Next of Kin Name Relationship Next of Kin Address (If different from Permanent Address) Next of Kin Phone Female Date of Birth PPS Nation of Birth Nation of Citizenship Mother Tongue CLOSING DATE FOR APPLICATIONS is ASAP, as demand for places is high. Return Completed Applications to: CESBEM Administrator, Development Unit, LIT Tipperary, Nenagh Road, Thurles, Co. Tipperary Tel: (0504) 28117 Fax: (0504) 28001 Email: edel.ogrady@lit.ie CESBEM V Application Form Page 1 of 6
2. TRAINING DATES Please indicate your preferred choices of dates for training. Please indicate preference by entering 1, 2, 3, 4 or 5 in order of priority Prior to the completion of this section please read the Overview of the CESBEM programme and Terms and Conditions carefully as this may affect your decision. Please note: Language and culture training has to be completed. This training will be parttime in the evening with some weekend sessions. This training will be in the location identified beside each Group below. While Group 1 L&C Training will take place in Limerick, Groups 2, 3, 4 & 5 location may vary. Technical training (delivered in English) will occur over two weeks. The training periods in Germany are fixed and will not be changed. You will be expected to be away for the full two weeks at the KOMZET Training site in Germany. Every effort will be made to accommodate people on their 1st preference but there are only approximately 20 places per travel period and therefore you may be offered a non-first preference option. Preference Group No. Language and Cultural Training Dates between Language and Cultural Training Location Training Dates in Germany Group 1 Already Complete LIT Limerick Already Complete Group 2 Already Complete LIT Clonmel Already Complete Group 3 31 st August 14 to 21 st September 14 Mountrath, Co. Laois 21 st September 14 to 5 th October 14 Group 4 9 th November 14 to 29 th November 14 LIT Limerick 29 th November 14 to 13 th December 14 Group 5 29 th March 15 to 19 th April 15 TBC 19 th April 15 to 3 rd May 15 I confirm that if my application is successful, that I am available to travel on the dates indicated above. Have you ever before received funding under the Leonardo Da Vinci European Mobility Fund? Yes / No If Yes, please state name of programme and Institute attended; Signed: Date: CESBEM V Application Form Page 2 of 6
SECTION B Note: The questions asked in Section B are required for the purpose of scoring your application; please ensure they are completed correctly and completely. 3. EDUCATIONAL HISTORY Secondary School Education Name of School Address Dates From: To: Did you complete the *Junior Certificate / *Intermediate Certificate? Yes No Did you complete the *Leaving Certificate? Yes No FETAC Qualification Do you have a full *FETAC Award? Yes No Name of School / College: Title of Qualification: Level of Award: Third Level Qualification Did you ever attend a Third Level College? Yes No Name of College: Title of *Programme: Did you complete the Programme? Yes No Date of Entry: Date Conferred: Grade: CESBEM V Application Form Page 3 of 6
Please list other educational qualifications/training programmes you have attended: Continue on an additional sheet if required Course(s) Provider(s) Name (who ran the course) Qualification(s) (if any) Year(s) *Please ensure that you fully complete all questions and attach copies of certificates / results where relevant as incomplete applications will be returned which will cause unnecessary delays in the processing of your application. 4. EMPLOYMENT HISTORY in or related to the Construction Sector Provide details of relevant work experience (if any): Provide additional details on additional sheets if required or enclose CV in EuroPass Format Are you currently unemployed? Yes No Current Occupation (or last Construction Sector related occupation if currently unemployed): Employer s Details (if appropriate) - state if you are self-employed: Nature of Business: Please provide us with a brief description of your duties and responsibilities: CESBEM V Application Form Page 4 of 6
5. WHY YOU WANT TO ATTEND THE TRAINING Reasons for applying to participate in this training programme. The education, training, interests or knowledge that would make you a suitable candidate for this programme. The kind of things you expect to learn on this programme that would particularly appeal to you. How you would expect the successful completion of this programme to help you in your future life and/or career. 6. INFORMATION TECHNOLOGY SKILLS Describe your current level of skills in the use of computers by answering the following; Do you regularly use a computer for your work? Yes No What do you use the computer for? What computer applications (e.g. Internet Explorer, Word etc.) do you use? Do you have any particular skills with computer applications relevant to this training programme? CESBEM V Application Form Page 5 of 6
7. GERMAN LANGUAGE PROFICIENCY The CESBEM programme includes a specific programme of language and cultural preparation. Please indicate if you have any experience in the German Language; Yes No I am currently studying the German language I have previously studied the German Language I am capable of holding a conversation in German 8. DECLARATION Data Protection LIT Tipperary fully respects your right to privacy. Any personal information you volunteer to LIT Tipperary will be treated with the highest standards of security and confidentiality, strictly in accordance with the Data Protection Act, 1988 & 2003. Declaration (Must be signed by all applicants). I confirm that the information on this form is correct to the best of my knowledge. I agree to abide by the rules and regulations of the Institute, should I be offered and accept a place. Please see www.lit.ie/foi/section16 for the Institute s Rules & Regulations. I also confirm that I am available to travel on the dates indicated for the training programme and to participate in the language/cultural training aspect of the programme, which must be completed prior to travel to KOMZET, Germany. I also undertake to complete and provide to the Institute any documentation and evaluation forms as required under the programme. Signature: Date: Please note If you are deemed eligible on the basis of your application form, you will then be requested to attend an interview / information session, which is the final element of the selection process, before a place on the course is offered. If you are accepted on the course, you will (at a later stage) have to submit a copy of your EHIC Card (European Health Insurance Card [formerly the E111 form]) see http://www.ehic.ie/ and a copy of your current passport. You should consider applying for the EHIC card now and also check your passport is valid for dates for travel. CLOSING DATE FOR APPLICATIONS is ASAP, as demand for places is high. CESBEM V Application Form Page 6 of 6