APPLICATION FORM Monitoring To help us work towards fair representation, please answer the following questions: Course details Do you identify yourself as being: Course date: 5 December White British Course title: Health and Safety Seminar Irish Any other White background Course code (if known) Mixed race White & Black Caribbean Closing date for the course: 30 November White & Asian Your details Any other Mixed background Male Female Other Asian or Surname Asian British Indian Pakistani First name Any other Asian background Membership no. Black & Branch Black British Caribbean African Service group (e.g Health, Local Gov) Any other Black background Chinese or Address for correspondence other ethnic Chinese group Any other ethnic background Contact no. Mobile ------------------------------------------------------ Please provide your email address below All applications must ask their Branch so we can send joining instructions by Secretary/Branch Education Officer to email: complete this section. Any problems should Email be referred to the Regional Education Officer on 01483 406511 Facilities Important note: please ensure membership Do you have special dietary needs? Yes / No numbers of all applicants are shown on all Are you disabled? Yes / No application forms to assist with administration. Do you have any access needs? Yes / No Do you need assistance with This application is supported by the Branch child/dependent care to attend this course? Yes / No Signed Date If you have answered yes to any of the above Branch position please give details: Return to: ____________________________________ Suzanne Tipping, UNISON, Christchurch House, ____________________________________ Beaufort Court, Sir Thomas Longley Road, Strood, Kent ME2 4FX PLACES ON COURSES CANNOT BE fax to: 01634 717848 GUARANTEED THEREFORE YOU ARE Email to: s.tipping@unison.co.uk ADVISED NOT TO MAKE TRAVEL/HOTEL ARRANGEMENTS UNTIL A PLACE HAS BEEN CONFIRMED
APPLICATION FORM Course details Course date: 5 December Course title: Health and Safety Seminar Course code (if known) Closing date for the course: 30 November Your details Male Female Other Surname First name Membership no. Branch Service group (e.g Health, Local Gov) Address for correspondence Contact no. Mobile Please provide your email address below so we can send joining instructions by email: Email Facilities Do you have special dietary needs? Yes / No Are you disabled? Yes / No Do you have any access needs? Yes / No Do you need assistance with child/dependent care to attend this course? Yes / No If you have answered yes to any of the above please give details: ____________________________________ ____________________________________ PLACES ON COURSES CANNOT BE GUARANTEED THEREFORE YOU ARE ADVISED NOT TO MAKE TRAVEL/HOTEL ARRANGEMENTS UNTIL A PLACE HAS BEEN CONFIRMED Monitoring To help us work towards fair representation, please answer the following questions: Do you identify yourself as being: White British Irish Any other White background Mixed race White & Black Caribbean White & Asian Any other Mixed background Asian or Asian British Indian Pakistani Any other Asian background Black & Black British Caribbean African Any other Black background Chinese or other ethnic Chinese group Any other ethnic background ------------------------------------------------------ All applications must ask their Branch Secretary/Branch Education Officer to complete this section. Any problems should be referred to the Regional Education Officer on 01483 406511 Important note: please ensure membership numbers of all applicants are shown on all application forms to assist with administration. This application is supported by the Branch Signed Date Branch position Return to: Suzanne Tipping, UNISON, Christchurch House, Beaufort Court, Sir Thomas Longley Road, Strood, Kent ME2 4FX fax to: 01634 717848 Email to: s.tipping@unison.co.uk