<p> JMC/AIM AWARDS LEVEL 6 DIPLOMA IN PSYCHOTHERAPEUTIC COUNSELLING</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 & 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</p><p>Please give details of counselling placement or counselling employer</p><p>Please give name, address and contact number for your current clinical counselling supervisor (we will contact your supervisor for a reference).</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</p><p>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>THE LAW NOW REQUIRES US TO MONITOR THE COMPOSITION OF ALL APPLICANTS 3 60 Cluaneo Meadows, Coalisland, Co. Tyrone BT71 5EN, Tel 028 8774 6582</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. This information will be kept confidential at all times and will not be used by management in assessing an applicant’s suitability for a place on this course. 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 </p>