Personal Details (Please Print)
Forename(s):
Title: Mr/Mrs/Miss/Other: / Surname:
Current Address:
Postcode: / Email Address:
Landline No: / Mobile No:
Current/last APC Number: / Expiry Date: / Existing Awarding organisation:
BDA/DA/Patoss
Please provide your BDA Professional Membership number and expiry date, this is not your AMBDA number. / M0…..
Expiry

With this renewal you must submitthe following:

  1. Full diagnostic assessment report – anonymised(Do NOT send working papers

but retain them as they may be requested by the APC marker)

  1. Anonymised assessment Log
  2. APC CPD Log
  3. Training and development plan for the next 3 years

Certificate

Please indicate how you would like your name to appear on your Assessment Practising Certificate (APC). Please use BLOCK CAPITALS:

SASC List of Assessment Practising Certificate (APC) Holders

SASC charge a mandatory fee of £15 for listingAPC holders on the SASC website, this is included in the APC fee. The information listed currently includes: full name, APC number, awarding organisation, start date and expiry date.

Permission to share details with SASC (SpLD Assessments Standard Committee) to activate associate membership

To activate your associate membership, SASC requires your contact details to be provided by your APC issuing body - name, email and address.Your contact information will be shared with SASC for the purposes of

1activating your Associate Membership with SASC

2SASC providing communication to you

These details will only be used by SASC for the purposes of SASC membership activities and communications. The publicly available information remains limited to name, certificate number, issue date and expiry date.

Consent declaration - please select your preference

□I consent to you sharing my personal information with SASC to activate my SASC Associate Membership as follows: Name, email, address

□ I wish to activate my SASC Associate Membership and agree to share my details with SASC as follows: Name, email, address, but do not wish to receive any communication from SASC

□ I wish to opt out of SASC Associate Membership. Do not share my details with SASC.

Data Protection

By completing this form, you are agreeing for us to administer your BDA Professional Membership and where necessary share your information internally within the BDA.

From time to time we may like to send you information about our own products and services that you might be interested in, by post, telephone, email and SMS. We will not pass your information on to any organisation external to the BDA.

If you agree to being contacted in this way, please tick the relevant boxes to indicate how you would like to be contacted:

Email SMSPost Telephone

The BDA is committed to protecting your personal data please see our Privacy Policy on our website at:

Declaration: Please read and tick each box, sign and date.

I confirm that the information provided is true and accurate
I agree to abide by the BDA Code of Ethics and Conduct
I agree to maintain a CPD Portfolio every three years and understand that this is a condition of renewal
I am a Professional Member and recognise that my APC is only valid so long as I maintain this membership
I agree to pay £165 fee and understand that this is non- refundable and that If I have to resubmit a second report there is a remarking fee of £110 payable
The submitted diagnostic report is my own work and has not been submitted to any other APC awarding organisation
I enclose copies of any relevant documents and recognise that these are non-returnable but that I may be asked for originals. Original documents will be returned.
I understand that my submission may be used anonymously for training and moderation purposes within and between issuing and awarding bodies.
Signed / Date

CHECKLIST

 APC renewal form
 Diagnostic Assessment Report (anonymised)
 Assessment Log (anonymised)
 CPD Log
 Training and Development Plan
 Professional Membership, £68 paid annually by direct debit
 Payment of £165 renewal fee
 Two copies of all documents

Payment Options

Please note that payment is processed on receipt of application but does not imply that accreditation has been awarded
Cheques: Made payable to British Dyslexia Association, include with application
Bank transfers: British Dyslexia Association Sort Code: 20-71-06 Account: 90286141
International: IBAN GB05 BARC 2071 0690 2861 41/SWIFTBIC BARCGB22
Reference: APC your name
Credit/debitcards: Complete credit card form and send with application

Send your complete application for APC renewal to:

Accreditation, British Dyslexia Association, 6a Bracknell Beeches, Bracknell Lane West,

Bracknell RG12 7BW

Please make sure that you use the correct postage the Post Office will not deliver underpaid items

Credit Card Form APC Renewal

Please debit my account with the amount of £165.00

Card number:

X / X / X

Security No Expiry Date:

Name as it appears on the card

Cardholder’s signature Date

Please note that payment will be taken on receipt of application

If you require a receipt, provide an email address below:

BDA January 2018APC Renewal

Registered Charity No. 289243 Limited Company: No. 1830587