CPD Short Course application

Workshop date

Please select your chosen date

Applicant details

Title

Surname

Forename(s)

Previous name (if applicable)

Date of birth

Date of birth - DayDate of birth - MonthDate of birth - Year

Home address

Postcode

Contact telephone number

Contact email address

Emergency contact details

Emergency contact

Emergency contact telephone number

Employer/workshop fee information

Organisation

Job title

Work email address

Please indicate who will be responsible for paying fees. Please tick one box.

Self-funding (the workshop fee invoice will be sent to your home address)

Employer (please provide further information below)

If a place on the selected workshop is available, it will be reserved. This will only be confirmed once a purchase order for the workshop fee has been provided.

Invoice address

Postcode

Contact person

Contact telephone number

Email address for invoice

PO number (if currently available)

Disclosure information

Do you have any additional requirements? The information you provide will be treated confidentially and will not affect judgements concerning your academic suitability for the course.

If yes, please specify

Are you happy to work on pigs trotters and shoulders?

Equal Opportunities Monitoring

As part of its equal opportunities policy, Birmingham City University carries out regular monitoring of student enrolments by gender, ethnic origin and disability. Provision of information on ethnic origin is voluntary, but we hope you will agree to provide it to assist us in the implementation of our equal opportunities policy.

Please select appropriate boxes below.

Gender

Ethnic origin

Disability

Declaration

I accept that if it is discovered that I have supplied false, inaccurate or misleading information, Birmingham City University reserves the right to cancel my application, withdraw its offer of a place or terminate attendance at the University and I shall have no claim against Birmingham City University in relation thereto.

Yes

I confirm that the information given on this form is true, complete and accurate and that none of the information requested or other material information has been omitted.

Yes