Title
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Mr
Mrs
Ms
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First Name
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Surname
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Sex
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Male
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DOB (You must be 19 or over)
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Address
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Post Code
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Telephone Number
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Mobile Number
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Email Address
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Emergency Contact Name
Emergency Contact Telephone
Emergency Contact Relationship
Ethnicity
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English/Welsh/Scottish/Northern Irish/British
White and Black Caribbean
White and Black African
White and Asian
Any other mixed/multiple ethnic background
Irish
Indian
Bangladeshi
Pakistani
Chinese
Any other Asian background
Gypsy/Irish Traveller
African
Caribbean
Any other Black/African/Caribbean/Black British background
Arab
Any other white background
Any other ethnic group
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Do you consider yourself to have a disability, learning difficulty and/or health problem?
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Yes
No
Which of the above is your primary disability, learning difficulty or health problem? enter the number
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Qualifications already held (please select highest qualification)
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No formal qualifications
Entry level Entry 1,2 or 3; QCF award or certificate at entry level
Level 1 GCSEs grade D to G or 3 – 1; CSEs grade 2 – 5; GNVQ foundation; BTEC 1st certificate; NVQ level ; any other level 1
Level 2 5 x GCSEs grade A* to C or 9 to 4; 5 x O level passes; 5 CSEs grade 1; NVQ level 2; City & Guilds (C&G) level 2; any other level 2 qualification
Level 3 AS / A levels; GNVQ Advanced Diploma; NVQ level 3; C&G Level 3; BTEC National Cert. or Diploma; any other level 3 qualification
Level 4 Certificate of Higher Education; NVQ level 4; any other level 4 qualification
Level 5 Foundation Degree; NVQ level 5; any other level 5 qualification
Level 6 Bachelor’s Degree; any other level 6 qualification
Level 7 Masters/Postgraduates Degree; Doctorate; any other level 7 or above qualification
Other qualification – level not known
I don’t know what qualifications I have
How did you hear about the course?
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Attended previously
Family/Friend
Staff Member
Marketing
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Current employment status
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I am in paid employment
I am self employed
I am in employment and earn less than £32,000
I am not in paid employment, looking for work and available to start
I am not in paid employment, not looking for work, not available to start work (including retired)
Length of Employment
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Learner is employed for 0 to 10 hours per week
Learner is employed for 11 to 20 hours per week
Learner is employed for 21 to 30 hours per week
Learner is employed for 31+ hours per week
I was in full time education or training prior to enrolling
I Have been Employed For
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0-3 Months
4-6 Months
7-12 Months
12+ Months
National Insurance Number (Only required when applying for a qualification).
The European Social Fund The Education and Skills Funding Agency is also a co - financing organisation and uses European Social Funds from the European Union to directly or indirectly part - finance learning activities, helping develop employment by promoting employability, business spirit and equal opportunities, and investing in human resources. The English European Social Fund(ESF) Managing Authority(or agents acting on its behalf) may contact you in order for them to carry out research and evaluation to inform the effectiveness of training. You can agree to be contacted for other purposes by ticking any of the following boxes, this includes contact from Dudley Adult and Community Learning(ACL) Team.
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