<p> LEVEL 5 DIPLOMA IN THERAPEUTIC COUNSELLING</p><p>Ref No:</p><p>SECTION 1.PLEASE COMPLETE THIS SECTION IN BLOCK CAPITALS</p><p>Mr/Mrs/Miss/Ms Surname Forename</p><p>Previous Name(s) </p><p>Address</p><p>Postcode Tel No. Home </p><p>Mobile Email</p><p>Date of Birth National Insurance No. </p><p>SECTION 2: QUALIFICATIONS (Counselling and counselling related only).</p><p>Description of Date(s) obtained Exams taken and grade qualification</p><p>1 60 Cluaneo Meadows, Coalisland, Co. Tyrone BT71 5EN, Tel 028 8774 6582 [email protected] www.jmccounsellingandtraining.co.uk Please give details of any other training, qualifications courses including seminars meetings and memberships you feel is relevant to your application.</p><p>SECTION 3. Present/most recent Employment. (If unemployed state unemployed)</p><p>Name and address of Employer Place of work</p><p>Postcode Date appointed</p><p>Position Held Full Time-Part Time</p><p>Please provide a summary of your main duties and responsibility.</p><p>2 60 Cluaneo Meadows, Coalisland, Co. Tyrone BT71 5EN, Tel 028 8774 6582 [email protected] www.jmccounsellingandtraining.co.uk SECTION 4 GENERAL DETAILS.</p><p>Declaration of criminal Offences. Please give details of any criminal convictions and indicate if you have none. We also require details of spent convictions.</p><p>Additional Information. Please state your reasons how you feel this course of study would best suit you. </p><p>Signed Date</p><p>3 60 Cluaneo Meadows, Coalisland, Co. Tyrone BT71 5EN, Tel 028 8774 6582 [email protected] www.jmccounsellingandtraining.co.uk THE LAW NOW REQUIRES US TO MONITOR THE COMPOSITION OF ALL APPLICANTS</p><p>Personal Reference No:</p><p>Please note that the following information is required to fulfil a legal obligation and is necessary to enable us to check and to demonstrate to others that our application process is fair and equitable.</p><p>This information will be kept confidential at all times and will not be used by management in assessing an applicants suitability for a place on this course.</p><p>We require you to complete the questionnaire on this page and return the completed form to our monitoring officer in the enclosed envelope. </p><p>PLEASE INDICATE BY TICKING THE APPROPRIATE BOX BELOW:</p><p>1. My Perceived religious affiliation is:</p><p>Catholic Protestant Other</p><p>2. Gender, Marital status, Family status:</p><p>A) My sex is: Male Female</p><p> b) My Marital status is: Married Single Other c) My family status is: No caring responsibilities </p><p>Care for other relative Care for children Other </p><p>3. Disability: a) Do you consider yourself to have a disability? Yes No b) If yes, what is the nature of your disability?</p><p>If allocated a place on the course what adjustments/arrangements would you require: (e.g. mobility, access to rooms, teaching aids etc.)</p><p>4 60 Cluaneo Meadows, Coalisland, Co. Tyrone BT71 5EN, Tel 028 8774 6582 [email protected] www.jmccounsellingandtraining.co.uk</p>