Learner Self-Declaration of Eligibility

Learner Self-Declaration of Eligibility

Learner Name:Job Title:

Email:Contact phone number:

Company Name:Company post code:

To check that you are eligible to receive funding for this qualification please answer each question by circling your response.
Are you 19 or over? / YES / NO
Can you confirm you have not achieved a level 2 qualification, equivalent or higher? For example, 5 GCSEs at grades A*-C, 1 A Level, GNVQ Intermediate. / YES / NO
Please state your highest qualification and country where you achieved it?
Can you confirm you are not enrolled on a funded course of training or education involving 16 or more hours of study per week? / YES / NO
Have you previously completed an NVQ or Apprenticeship? If yes, please specify: / YES / NO
Do you have the legal right to be resident in the UK and the EEA (European Economic Area)? / YES / NO
Have you been living in the UK for more than three years, not on a Student Visa? / YES / NO
If you have answered "no" to the previous question, are you married to an EEA Citizen and have been living in the UK for at least one year? / YES / NO
Please list the countries where you have lived in the last three years.
Do you currently have a contract of employment with your employer? / YES / NO
Are you on a temporary contract? / YES / NO
If you are on a temporary contract please state its anticipated duration:
Please state your contracted hours today:
Any other Comments :

Privacy Statement- How we use your personal information.

The personal information you provide is passed to the Chief Executive of Skills Funding (“the Agency”) and, when needed, the Young People’s Learning Agency for England (“the YPLA”) to meet legal duties under the Apprenticeships, Skills, Children and Learning Act 2009, and for the Agency’s Learning Records Service (LRS) to create and maintain a unique learner number (ULN). The information you provide may be shared with other partner organisations for purposes relating to education or training.

Further information about use of and access to your personal data, and details of partner organisations are available at:

I declare that I have correctly identified my prior qualifications and eligibility on this form. I understand that if I have declared false information the provider may take action against me to reclaim the tuition fees and any support costs incurred.

Learner Signature:______Date: ______

I confirm that to the best of my knowledge the information on this form is correct. I confirm that the learner has a current contract of employment, or is a self employed contractor working for the Company, or is a temporary worker on assignment at the Company.

Employer Signature:______Date:______

Information for Skills Broker:

If this is the case of / Make copies of
1 / Learner with UK passport / Nothing. Just write the passport number in the space below
2 / Learner with EEA passport / Front cover of passport, first page (showing passport number) and Page with picture
3 / Learner with any other passport / Front cover of passport, first page (showing passport number) and Page with picture
Additionally, current visa and ALL visas that the learner has had in the last three years
4 / UK citizen without a passport / Birth Certificate (showing name of parents) and proof of NINO
5 / EU citizen without a passport / Identity card
6 / Spouse of a Non EEA citizen with a working visa / Front cover of passport, first page (showing passport number) and Page with picture
Additionally, current visa and ALL visas that the learner has have in the last three years
7 / Non EEA citizen married to an EEA citizen and has been within the UK for more than a year and less than 3 years / For both (learner and EEA citizen): Front cover of passport, first page (showing passport number) and Page with picture
For learner: Additionally, current visa and ALL visas that the learner has had in the last three years
Marriage certificate or copy of spouse visa with both names on it.

I confirm that I have checked the eligibility of ______(Learner Name) for the Work Place Learning contract and have seen/copied the documents relevant to point _____ above.

For UK passports only, Skills Broker please record here the passport number after you have seen the original ______

Skills Broker Name: / Skills Broker signature:
Date: / Provider Name: