Surname	Forenames

Address

Postcode Email

Gender Date of Birth Age NI Number

Male
Female

Telephone Mobile

Your Proposed Apprenticeship Programme

Name and Address of Past/Present School or College Attended

Qualifications

Please enter below any examinations already taken with the grade achieved or for which you are awaiting results.
Also list current qualifications you are studying e.g. GCSEs, AS Levels, BTECs etc.

Year Taken	Subject	Level	Grade (if known)

Have you completed year 11 at school?			Have you been on worked based learning before?
Yes No			Yes No

Are you still in full time education or training?
Yes No

Employment

Are you currently employed?
Yes No
Your Job Title

Employers Name and Address

Please give a brief description of your current roles and responsibilities

Other Information

Do you have a learning difficulty/disability or medical condition we need to be aware of?
Yes No
If yes please specify

Please give details of any activities that you are involved in, interests that you have or any possible career plans.

Do you hold a full UK driving licence? Do you have access to a car?

Yes
No Yes
No

How did you hear about the programme?
Connexions	Seevic College	School	Event
Website	Other (please specify)

Have you been legally resident in the UK/European Union for the last three years?

Yes
No

Do you have a criminal conviction, formal conviction, reprimand or final warning from the Police?
This will be discussed at your interview.

Yes
No

By submitting this form I certify that the information I have given on this form is correct and I give my consent to the processing and sharing of this information for all purposes relating to my application*.

*Data on your proposed course will be held on computer and used to analyse applications and support curriculum planning.