Payment details
(NB. Courses and Examinantions may not be arranged unless payment isreceived in full with this application or prior invoicing arrangements have
been made)
Cheques payable to:- Bounty Consultancy Services Ltd
BACS payment details:-Sort Code: 090129 Account number: 13544939Please use either invoice number or surname as reference
Invoicing Address (if different to personal details):-
Contact Name:-
Address:
Postcode: County:
Telephone No.
LEARNERREGISTRATION FORM
Please complete this form and return to the address
below
DATA PROTECTION ACT 1998: Personal information regarding yourself held by RSPH, or their Registered Centres, is retained and may be made available to certainstatutory bodies in the United Kingdom in accordance with our Data Protection Policy. You are regarded as having given your full consent (where required by the Act) to the holding and disclosure of such information supplied to RSPH as a condition of yourregistration with RSPH.
Mr Martin Rose-KingBounty Consultancy Services84 Ellingham Industrial Estate
Ellingham WayAshford
Kent, TN23 6JZ
Tel No. 01233 665817
Email:- [email protected] Centre Number 4683
RSPH Centre number 4683
Qualification applied for…………………………………………
Personal details (to be completed, in block capitals please, by the Candidate )
On the back of the photograph please print your name.
Alternatively, a photo can be emailed to:[email protected]
Title (Mr/Mrs/Ms/Miss) Other (please specify)
Surname:
First name(s): Date of Birth:
_ _ / _ _ / _ _ _ _ day month year
Permanent home address:
Postcode: County:
Telephone No. Fax No. Mobile No.
Email address:
Previous name/Maiden name:
Previous address: (if changed since last assessment)
Postcode: Please state:
Male Female
If you already hold an RSPH qualification please state your
Certificate No.................................................. Candidate No ...........................................
and/or Qualification Title ...........................................................................................
Please attach apassport sizedphotograph.
Please do not glueor staple throughthe image
Employer and Trainer/Centre details(if you are employed or undergoing training please state:)
Specific Requirements
Candidate’sSignature Date .............................
Employer Name: Contact Name:
Address:
Postcode: Country:
Telephone No. Fax No.
Trainer/Centre Name:
Instructor’s Name:
Preferred location for assessment (if any)
Place of work
Centre or training provider
Other (please state)
Do you have any particular requirements which may affect your learning? e.g. disability or learning difficulty
Disability: Yes No Please specify:
Learning
Difficulty: Yes No Please specify: