For a copy of this form in Braille or large print please contact the QTS team at firstname.lastname@example.org, or by phone on 020 7593 5394
Please complete all relevant sections in black ink and BLOCK CAPITALS. Where cross boxes appear please put a cross in those that apply.
Forename: Middle name(s): Surname: Previous surname(s): Title: Date of birth: Gender (m/f):
Y Y Y Y
UK National Insurance number:
Of which EEA state are you a national: Address:
Country: Telephone number: Mobile number: Email address:
Eligibility for qualified teacher status
a) In which EEA State are you recognised as a qualified school teacher?
b) Please indicate the eligibility condition you satisfy: i) You have successfully completed a course of post-secondary higher education of at least three years’ duration, as well as the professional training which may be required in addition to that postsecondary course. ii) In a member state where post-secondary higher education of at least three years is the normal requirement, you are recognised and permitted to practise as a qualified school teacher, having undertaken some lesser education and training in such a State (acquired rights). iii) You are recognised in an EEA state by virtue of qualifications obtained outside of the EEA and have three years’ certified professional experience in that state.
3 Teacher qualifications
Name of teacher qualification: Name of institution: Period of study: From: Date of award:
Y Y Y Y Y Y Y Y
Y Y Y Y
Subject(s) trained to teach:
Age range trained to teach: From: Please continue on a separate sheet if necessary
4 Higher Education qualification
(only complete if your initial teacher qualification was a postgraduate course) Name of qualification: Name of institution: Period of study: From: Date of award: Subject(s):
Y Y Y Y Y Y Y Y
Y Y Y Y
5 Particulars of employment as a school teacher undertaken in the last ten years Employer name and address: Date from: Date to: Subject(s) employed to teach: Age range taught From: To:
Disability Please put a cross in the box to indicate whether or not you have a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day-to-day activities (Section 1(1) of the Disability Discrimination Act 1995) Yes No
This information will be used to estimate the number of teachers with disabilities, as defined by the Disability Discrimination Act 1995. If you are not sure whether you consider yourself disabled as defined by the Act, or need information, please contact the Equality and Human Rights Commission on 0845 604 6610 (phone), 0845 604 6630 (fax), 0845 604 6620 (textphone), or visit www.equalityhumanrights.com Ethnicity: Please put a cross in one box to indicate your cultural background. This information will be used to estimate the number of teachers from different ethnic groups to enable the TA to track and help monitor equal opportunities for all teachers. White British Irish Other Black, Black British Caribbean African Other Asian, Asian British Indian Pakistani Bangladeshi Other Chinese, Chinese British or other ethnic background Chinese Other Mixed White & Black Caribbean White & Black African White & Asian Other Prefer not to state Put a cross here if you prefer not to state your ethnic group
I declare that the information above is correct and that I have not withheld any material information and that the translation(s) I have provided is/ are true and faithful translations. I understand that such answers shall be the basis on which my application will be considered. Signed: Date of Signature:
Checklist Please send photocopies of your documents, not originals...