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:- training@bountyconsultancyservices.co.ukRSPH 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:training@bountyconsultancyservices.co.uk

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: