Enhanced Learning Credits Application for Scheme Membership Please complete in BLOCK CAPITALS in black ink Circle correct answer for multiple choice questions PART 1 PERSONAL DETAILS – Service Number dd mm yy Surname Date of Birth Forename(s) Service RN RM Army RAF dd mm yy Rank Enlistment Date Branch, Specialisation, Trade, Arm or Service dd mm yy Last Day of Service (as appropriate to Service) Current Base/Unit Current Work Unit Stamp Address Postcode Country Email Address PART 2 EQUAL OPPORTUNITIES – Gender Male Female Ethnic Group Asian Black Chinese Mixed Ethnic PART 3 INDIVIDUAL DECLARATION – I confirm the accuracy of the details entered above: dd mm yy Signature Date Warning: It is an offence to make or conspire in making a false statement on or about this application. PART 4 DECLARATION BY EDUCATIONAL STAFFS – (or PERSONAL LEARNING ADVISOR) Surname/Initials Service Number (or Payroll Number) This declaration is made in accordance with the requirements of JSP 822, the Regulations 1975 and the Policy, Rules and Guidance governing Appointments and Activities “Outside dd mm yy Signature Date Email Address Telephone The information you provide on this form will be held on a database When completed please return to: by ELCAS. The data will be used solely for the administration of the ELCAS ELC Scheme and to monitor and evaluate its performance. The New Challenge House information relating to equal opportunities will only be used for International Drive statistical evaluation. The data held will not be disclosed to any Tewkesbury Business Park parties not involved in the ELC Scheme administration and Tewkesbury management. All data will be handled in accordance with the Data Gloucestershire Protection Act 2000. GL20 8UQ The application form is to be received by ELCAS not later than one calendar month after expiry of the relevant ELC Scheme entry ‘window’. ELC 001-01 20/12/16 08
Enhanced Learning Credits Application for Scheme Membership Please complete in BLOCK CAPITALS in black ink Circle correct answer for multiple choice questions PART 1 – PERSONAL DETAILS Service Number Surname Date of Birth dd mm yy Forename(s) Service RN RM Army RAF Rank Enlistment Date dd mm yy Branch, Specialisation, Trade, Arm or Service (as appropriate to Service) Last Day of Service dd mm yy Current Base/Unit Current Work Address Unit Stamp Postcode Country Email Address PART 2 – EQUAL OPPORTUNITIES Gender Male Female Ethnic Group Asian Black Chinese Mixed Ethnic PART 3 – INDIVIDUAL DECLARATION I confirm the accuracy of the details entered above: Signature Date dd mm yy Warning: It is an offence to make or conspire in making a false statement on or about this application. PART 4 – DECLARATION BY EDUCATIONAL STAFFS (or PERSONAL LEARNING ADVISOR) Surname/Initials Service Number (or Payroll Number) This declaration is made in accordance with the requirements of JSP 822, the Regulations 1975 and the Policy, Rules and Guidance governing “Outside Appointments and Activities Signature Date dd mm yy Email Address Telephone When completed please return to: ELCAS New Challenge House International Drive Tewkesbury Business Park Tewkesbury Gloucestershire GL20 8UQ The information you provide on this form will be held on a database by ELCAS. The data will be used solely for the administration of the ELC Scheme and to monitor and evaluate its performance. The information relating to equal opportunities will only be used for statistical evaluation. The data held will not be disclosed to any parties not involved in the ELC Scheme administration and management. All data will be handled in accordance with the Data Protection Act 2000. The application form is to be received by ELCAS not later than one calendar month after expiry of the relevant ELC Scheme entry ‘window’. ELC 001-01 20/12/16 08
elc%20001-01%20application%20form%20ver%208.docx