Please remember:
- if you are completing this form by hand; please use black ink, BLOCK CAPITALS and tick boxes as applicable. Please write ‘N/A’ (not
applicable) for sections that are not applicable to you.
- if you are completing this form by typing; confirm your answer by selecting the boxes and please do not delete any sections that are not
applicable to you, just type N/A (not applicable).
Which programme are you applying for? / Business Administration Customer Service I.T. Warehousing & Storage
Childcare Supported Teaching & Learning Pre-Apprenticeship Study Programme(age 16-18)
Traineeship (age 16-23)
Are you applying for a specific vacancy? / Yes No If yes, please completethe detailsbelow.
Reference No. or Postcode / Position / Company Name
Put N/A if you do not know this
How did you hear about us? / Recruit an Apprentice Our website Job Centre Continuing Learning
Friends/family School/College Please specify:
Other Please specify:
Your Personal Details(Please write clearly)
Title/Gender / Mr Mrs Ms Miss / Male Female
First Name (as shown on I.D. verification)
Surname (as shown on I.D. verification)
Maiden Name / Deed Poll Name Change(if applicable, please produce document)
Date of Birth / Age Group / 16-18 19-23
National Insurance No. (if you don’t have this please include reason)
Telephone No. / Mobile No.
Full Address including Postcode
Have you been a UK resident for more than 3 years? / Yes No Proof of residency will be required.
Can you provide I.D. verification? / Yes Which one can you provide?
Passport Provisional/Driving Licence Birth Certificate
No Please state reason:
Do you speak any other languages? / Yes Please specify:
No
Do you have a Support Agency?
e.g. Job Centre, Social Services / Yes Please complete details below.
No
Name of Agency and Branch or Postcode
Full Name of Advisor/Support Worker
Telephone/Mobile No.
Please continue on Page 2
About You
Recent leaver of: School Sixth Form/College Not applicable
Currently in education/training
Full-time Part-time / Name of place attending
Course(s)/training undertaking
Hours/days of attendance per week
Start Date
Expected End Date
Unemployed and not in education or training / Length of time unemployed
e.g. months/years
Details of any benefits you receive
e.g. Job Seeker's Allowance
Employed More than 16 hours per week Less than 16 hours per week
Are you ready to be interviewed by an employer straight away? / Yes No
Please tick any of the following that you would like support with and include any comments if you wish.
Support requested / Comments
English
Maths
I.T.
Confidence
Career Research
Interview Skills
C.V. Assistance
One-to-one support
e.g. dyslexia, dyscalculia.
Please give details
Any other support/things you would like to improve
Please specify or tick list provided
Do you have a preferred job role? / Yes No If yes, what would you like to do and why?
Please tick which are applicable
to you and include any further details if you wish. / A resident of the UK
A person with other care responsibilities
Pregnant/single parent
Drug/alcohol user
In need of special educational needs/Statemented
Excluded from school
Any further details:
Do you live with people who are unemployed and have dependent children? / 1 - No household member is in employment and the household includes one or more dependent children.
2- No household member is in employment and does not include any dependent student.
3 - Live in single adult house with dependent children.
99- Non applies (1,2,3)
Your home life
e.g. Who do you live with? Do you have any specific responsibilities?
Do you have any health issues or Learning difficulties?
e.g. Asthma, regular medical appointments / Yes No If yes, please give details or refer to the list provided
Hobbies/interests/likes/dislikes
e.g. music, food, sport
Any other relevant information
e.g. planned holidays
Education
Please continue on a separate sheet if necessary.
Date
From / Date
To / Name of School/College/Provider / Subjects/Exams Taken
include Level e.g. GCSE/Diploma/Functional Skills / Grades
Actual / Predicted
(if actual not received) / If predicted, due date of actual grades to be received
Maths
English
ICT
Any Level 3 Qualification?
What school/college did you attend at age 16 years / School Name: / Town/City
Can you provide certificates for your qualifications? / Yes No
Is there any reason it may be difficult for you to attend regularly and achieve any part of the course? / Yes No If yes, how can this be overcome?
Work Experience – Employment/Training/Voluntary
Please continue on a separate sheet if necessary
Date
From / Date
To / Name of
Company/Branch / Position Held / Brief Description of Duties / Reason for Leaving
You may put “See CV” here if you will bring one to interview
Disclosure of Information
Have you ever been convicted of a criminal offence or currently have charges outstanding? / Yes No If yes, please give details.
Which one of the following methods of contact do you prefer?
Please tick as many as you wish. / Text
Letter
Details of Parent/Guardian/Next of Kin
(or emergency contact if you live in Supported Accommodation)
Title / Mr Mrs Ms Miss
First Name / Mobile No.
Surname / Telephone No.
Relationship to you / E-mail
Full Address including Postcode / You may put 'see page 1' if they live at the same address as you.
Ethnicity / How We Use Your Personal Information
Please select which is applicable to you:
31 – White, British
32 – White, Irish
33 – Gypsy or Irish Traveller
34 – White Other
35 – White and Caribbean
36 – White and African
37 – White and Asian
38 – Other Mixed
39 – Indian
40 – Pakistani
41 – Bangladeshi
42 – Chinese
43 – Other Asian
44 – Black African
45 – Black Caribbean
46 – Black Other
47 – Arab
98 – Other
99 – Not known
ZZ – Prefer not to say / The personal information you provide is passed to the Chief Executive of Skills Funding (“the Agency”) and, when needed, the Education Funding Agency (“the EFA”) to meet legal duties under the Apprenticeships, Skills, Children and Learning Act 2009, and for the Agency’sLearning Records Service (LRS) to create and maintain a unique learner number (ULN).
Please read and initial
The information you provide may be shared with other partner organisations for purposes relating to education or training.
Please read and initial
Further information about use of and access to your personal data, and details of partner organisations are available at:
http://skillsfundingagency.bis.gov.uk/privacy.htm, www.efa.gov.uk,
Equal Opportunities Policy
We have an Equal Opportunities Policy that states we provide opportunities to develop the employment potential of all people, in respective of race, religion, gender, disability or unrelated criminal convictions.
Declaration
I confirm that the information provided on this form is, to the best of my knowledge, accurate and complete.
I confirm that I have read the ‘How We Use Your Personal Information’ section and I authorise my details to be checked/used for my application and also if I am accepted onto an Apprenticeship.
Signature:
Date:
Office Use only
Interview Outcome / Pre-Apprenticeship Study Programme – 16-18 Start Date/Notes:
Traineeship – 16-23 Start Date/Notes
App. Min. wage p/h: £3.40 (16-23/1st App) £4.00 (16-17/2nd App) £5.550 (18-20/2nd App) £6.95 (21-23/2nd App)
Referred elsewhere Specify:
Contact in future Specify:
Interview Details / Date/Time / Interviewer / Notes e.g. handwriting
List of Learning Difficulties or Disabilities and Health Problems
Code / LLDD or Health Problem / Tick if Applies04 / Visual impairment
05 / Hearing impairment
06 / Disability affecting mobility
07 / Profound complex disabilities
08 / Social and emotional difficulties
09 / Mental health difficulty
10 / Moderate learning difficulty
11 / Severe learning difficulty
12 / Dyslexia
13 / Dyscalculia
14 / Autism spectrum disorder
15 / Aspergers syndrome
16 / Temporary disability after illness or accident
17 / Speech, language and communication needs
93 / Other physical disability
94 / Other specific learning disability (e.g. dyspraxia)
95 / Other medical condition (e.g. epilepsy, asthma, diabetes)
97 / Other disability
99 / Prefer not to say
If you have ticked any of the above categories please write in the box below how this disability or condition could affect your ability to complete your Apprenticeship. Give as much detail as you feel able and continue on a separate sheet if necessary.
Applicant Signature: ...... Date:......
Applicant Name:......
Office Use Only:
ALS Status Required: Yes/No. Apprenticeship Duration Extended: Yes/No
Page 1 of 5
Rec – Letter/App Form/our map/20-Applicant Application Form
Rev Nov 16