Lean Six Sigma Green Belt Application Form

* Please complete in BLOCK CAPITAL LETTERS

* Use additional paper if necessary

Section A*

*Note:The questions in Section A are for information purposes only

1. Personal Information
Surname / First name
Prefix (please tick box) / Mr Mrs Ms Miss
Permanent Home Address / Address for Correspondence (if different from Home Address)
Home Phone / Mobile Phone
Email Address
Gender: / Male Female
Country of Birth
Nationality
PPS No. / Date of Birth
2. Training Dates

October 28th1600 – 1900 &Induction &

1900 - 2100Classroom Lecture Statistics

October 29th1800 – 2100On-line lecture Statistics

November 3rd0900 – 1700Classroom Lecture Lean Six Sigma

November 4th0900 – 1700Classroom Lecture Lean Six Sigma

November 5th0900 – 1700Classroom Lecture Lean Six Sigma

November 12th1800 – 2100On-line lecture Statistics

November 19th1800 – 2100On-line lecture Statistics

November 26th1800 – 2100On-line lecture Statistics

December3rd 1800 – 2100On-line lecture Statistics

December9th 1800 – 2100On-line lecture Statistics

December 10th 0900 – 1700Classroom Lecture Lean Six Sigma

December 11th0900 – 1700Classroom Lecture Lean Six Sigma

December 12th0900 – 1500Classroom Lecture Lean Six Sigma

December 12th1500 – 1700Classroom Lecture Statistics

December 17th1800 – 2100On-line lecture Statistics

December 22nd1800 – 2100On-line lecture Statistics

January 7th 1100 – 16002 X 2 hour exams

January 21st 0900 – 1700Panel Presentation

3. Educational History (School last attended)
Name of School
Address
Dates attended / From: / To:
Name of Final Examination
Year of Final Examination / *Attach results if available
Please list other educational qualifications and/or other training you have attended
Course(s) / Provider(s) name, address / Qualification(s) (if any achieved) / Year
*Attach results if available

*Please attach photocopies of original certificates only. You may be requested to present original copies in person to staff of ITB to confirm eligibility.

4. Employment History
Provide details of relevant work experience (if any)
Additional detail may be provide on additional sheets if required
Current Occupation (or last occupation if currently unemployed):
Employers details (please state if self-employed):
Nature of Business:
Please provide a brief description of your duties and responsibilities:
5. Reasons for attending programme
Please provide a brief description of the following:
Your reasons for applying to participate on the programme:
Have you identified a work based improvement project that may form the basis for your course project?
6. Declaration
Data Protection
Institute of Technology Blanchardstown fully respects your right to privacy. Any personal information you volunteer to Institute of Technology Blanchardstown will be treated with the highest standards of security and confidentiality, strictly in accordance with the Data Protection Act, 1988 & 2003.
Declaration
(Must be signed by all applicants).
I confirm that the information on this form is correct to the best of my knowledge. I agree to abide by the rules and regulations of the Institute, should I be offered and accept a place.
I also undertake to complete and provide to the Institute any documentation and evaluation forms as required under the programme.
Signature: / Date:

IMPORTANT

Note: while candidates who complete the Lean Six Sigma Green Belt Programme will have the capability to sit the American Society for Quality (ASQ) Six Sigma Green Belt examination, eligibility will be determined solely by the ASQ.

Please contact Theresa Vallom at 01 8851017 or Shane Walsh at 01 8851026 if you require any assistance.

All completed forms should be returned to:

Theresa Vallom

The LINC

Institute of Technology Blanchardstown

Blanchardstown Road North

Dublin 15

Lean Six Sigma Green Belt_Application_Form_ITB_Oct14