|
Title |
|
Bold indicates a required field. |
| First
name |
Your
given name |
|
Surname
/Last Name /Family name |
|
|
Date of
Birth |
/
/
|
|
Your Existing
CIPS Student Number |
Enter 0000 if not issued |
|
Address |
|
| |
|
| |
|
|
City |
|
|
State |
|
|
Postal
Code/ Zip Code |
Enter 0000 if
not applicable |
|
Country |
|
|
Email |
Please
ensure valid email
|
| Alternative
Email |
Re-enter
email above if alternative not available
|
|
Tel |
Enter Country,
Area Code, Tel No. |
|
Address
to
send your course materials (if this is different from your
address) |
|
| |
|
| |
|
|
City |
|
|
State |
|
|
Postal Code/
Zip Code |
Enter 0000 if not
applicable |
|
Country |
|
|
Highest
qualification held |
|
|
Job Title |
|
|
Years of
work experience |
|
|
Programme
Applied |
|
|
Modules
wish to take |
|
|
Tutor
Support Required |
Yes
No |
|
|
Study
Materials Required |
Yes
No |
|
|
Whether
you know the fees for Distance Learning |
Yes
No |
|
Payment
Method |
|
|
|
Credit
Card Type (If paying by Credit Card) |
|
|
|
Comment |
|
[Please indicate subject(s) for which you may have applied for exemption] |