Employer Contact Details: Company Name: (Only complete if this is the employer offering you an Contact Name: apprenticeship) Address: Telephone: Email: When did this employment start? Have you completed or part completed an Apprenticeship before? If so, please provide details. (If yes Do you consider that you have a disability or learning difficulty? please select from the options below) Yes No 4 Visual impairment 16 Temporary disability after illness (for example 5 Hearing impairment or accident 6 Disability affecting mobility 93 Other physical disability 7 Profound complex disabilities 94 Other Specific Learning Difficulty (e.g. Dyspraxia) 8 Social and emotional difficulties 95 Other medical condition (for example epilepsy, 9 Mental health difficulty asthma, diabetes) 10 Moderate Learning Difficulty 96 learning difficulty 11 Severe Learning Difficulty Dyslexia 97 Other disability 12 98 Prefer not to say 14 Autism Spectrum Disorder 15 Asperger’s syndrome Thank you for providing this information & we look forward to assisting you with an Apprenticeship. Please return to the sender of this email for processing.
Employer Contact Details: (Only complete if this is the employer offering you an apprenticeship) Company Name: Contact Name: Address: Telephone: Email: When did this employment start? Have you completed or part completed an Apprenticeship before? If so, please provide details. Do you consider that you have a disability or learning difficulty? (If yes please select from the options below) Yes No 4 5 6 7 8 9 10 11 12 14 15 Visual impairment Hearing impairment Disability affecting mobility Profound complex disabilities Social and emotional difficulties Mental health difficulty Moderate Learning Difficulty Severe Learning Difficulty Dyslexia Autism Spectrum Disorder Asperger’s syndrome 16 93 94 95 96 97 98 Temporary disability after illness (for example or accident Other physical disability Other Specific Learning Difficulty (e.g. Dyspraxia) Other medical condition (for example epilepsy, asthma, diabetes) learning difficulty Other disability Prefer not to say Thank you for providing this information & we look forward to assisting you with an Apprenticeship. Please return to the sender of this email for processing.
Apprenticeship-Enquiry-Form-2016-17.docx