Please complete all sections in BLOCK CAPITALS as this information will be used to create an electronic learner record, should you choose to start a programme of learning with us. Ensure you sign the declaration on page 5.

If you require any assistance or clarification with completing this application, please contact us:Call: 03332 408302 Fax: 01543 462 822      Email: info@ptp-training.co.uk

Please state the occupational area/programme of learning you are interested in: (e.g. IT, Literacy) Hospitality Services

SECTION 1: PERSONAL DETAILS Title First Name(s) Last Name

Mrs Ann ExampleNational Insurance Number Date of Birth Gender

A B - 1 2 - 3 4 - 5 6 - Z 0 7 0 4 1 9 7 0 Male Female

If you have not yet been issued with a national insurance number you will need this at the point you start a programme.

Please tick the box that describes your ethnic origin

White Mixed/Multiple Ethnic Group

Asian / Asian British Black / African / Caribbean/ Black British

Other Ethnic Group

31 English/Welsh/Scottish/

Northern Irish / British32 Irish33 Gypsy or Irish Traveller34 Other white background

35 White & Black Caribbean

36 White & Black African37 White & Asian38 Other mixed/multiple

ethnic background

39 Indian40 Pakistani41 Bangladeshi42 Chinese43 Other Asian

background

44 African 45 Caribbean 46 Other Black/African /

Caribbean background

47 Arab 98 Other ethnic

group

99 Not provided

Where ‘Other’ box has been ticked, please give details:

In order to assess your eligibility for possible funding, we need details on your residency status and length of time you have lived in the UK. Temporary absences from the UK should be ignored. If you have not been resident because you, or your parent or spouse were working temporarily abroad, you will be treated as though you have been ordinarily resident in the UK.

Where were you born? (Please state country) ENGLANDHow long have you lived in the UK and islands? (please tick the appropriate box)

Since birth More than 3 years Less than 3 years

Did you enter the country as a dependent? -

Has any time during the last 3 years been spent in full-time education? -

Current Permanent Home Address Postcode 123 LONG LANEWOLVERHAMPTON W V 1 5 3 R H

Home Telephone Number -

Personal E-Mail Address Mobile Telephone Number ann.example@gmail.com 079964315123

How long have you lived at the above address? 46 Years 3 Months

If less than 3 years record your previous address(es) during the last 3 years (including addresses outside the UK)

Address Post Code (if UK) Country Dates from and to

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LEARNER APPLICATION FORMProvider Ref:

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SECTION 2: QUALIFICATIONS AND TRAINING

Are you currently studying any qualifications? NO If YES please give details

Organisation Studying With: Qualification Being Studied: Start Date: Expected Finish Date: Funded By: Hours

Per Week:

QUALIFICATIONS Please list ALL qualifications and certificates gained (e.g. GCSEs, A’ Levels, Degree, O’ Levels, GNVQs,

Apprenticeships, NVQs, Key Skills, etc.) including those gained at school. Also list any certified training undertaken. Your Personal Learning Record, where available, will also be accessed by us to verify qualifications.

Organisation Qualification Title/Certified Training Grade or Level Achieved Date Achieved

e.g. Wood Green High School ‘O’ Level English Language C June 1984SHELFIELD HIGH ENGLISH LANG F JUNE 1986

“ ENGLISH LIT E JUNE 1986“ COMMERCE C JUNE 1986

MATHS E JUNE 1986SHELFIELD COLLEGE KEY SKILLS IN COMMUNICATION Level 1 MAY 2011

If you are aged 16-19, what date did you leave Year 11? Month Year

Have you worked towards, but not completed, any qualifications with another provider/college? NOIf YES, please give details

Provider/College Name: Qualification Studied: Dates To and From:

SECTION 3: SUPPORT IN LEARNING

Do you think you may need support with English or Maths? MATHS

If YES, please give brief details NOT TOO CONFIDENT ALL ROUND

Do you consider yourself to have a disability, learning difficulty and / or health problems? NOIf YES, please tick whichever applies to you (you can tick more than one category)

04 visual impairment 05 hearing impairment 06 disability affecting mobility 07 profound complex disabilities 08 social and emotional difficulties09 mental health difficulty10 moderate learning difficulty 11 severe learning difficulty 12 dyslexia 13 dyscalculia (difficulty with numbers)

14 autism spectrum disorder 15 aspergers syndrome16 temporary disability after illness (e.g. post viral) or accident 17 Speech, language and communication needs93 other physical disability94 other specific learning difficulty (e.g. dyspraxia)95 other medical condition (e.g. epilepsy, asthma, diabetes) 96 other learning difficulty97 other disability98 prefer not to say

If you have ticked more than one category, please state the ONE that you consider to be your main or most significant disability, learning difficulty or health problem that affects education.

Please indicate below if any health issues affect the type of work or training you can undertake: n/a

The Disability Discrimination Act 1995 defines a disabled person as someone who has a physical or mental impairment which has a substantial and adverse long-term effect on his or her ability to carry out normal day-to-day activities.Do you consider yourself to be a disabled person? NO

Local Authority Support

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Are you currently being supported by the Local Authority (e.g. living under Local Authority care, you are a care leaver, you have a Learning Difficulty Assessment, or Education Health & Care Plan)* NO

If YES, please give brief details

* Any information you provide will be treated in confidence and used to ensure you receive the support to which you are entitled. By declaring this information you agree to us liaising with appropriate external organisations to support you where appropriate.

SECTION 4: LEARNING STYLES

We would like to learn a little about how you learn. For each question on the left, please circle either A, B or C to indicate which statement most represents how you generally behave. Your Interviewer will discuss the results with you.

QUESTIONS INITIAL INDICATIONSWhen operating new equipment you prefer to Mainly A’s -

Your preferred learning style may be VISUAL You will remember things best when you've seen them. You will like a stimulating and orderly environment. You probably like to use diagrams and charts. You probably like reading, and may be a good speller. You learn best when visual aids are used such as displays, posters etc and need to be able to see the tutor in a classroom situation.

A Read the instructions first

B Listen to an explanation from someone

C Go ahead and have a go (you’ll figure it out as you use it)

During your free time you most enjoyA Going to museums and galleries, or watching films

B Listening to music and socialising with friends

C Playing sports, doing D.I.Y, cooking etc

If you were buying a new car you would initiallyMainly B’s –Your preferred learning style may be AUDITORYYou will learn best when you're listening (for example, in a lecture) and when you're involved in discussion. You will probably remember things best when you've listened to the instructions from an expert. You learn best when you talk things through, reciting facts or even singing them aloud, and may learn better with certain background noise such as music, or require silence to concentrate.

A Read reviews

B Listen to recommendations from friends

C Test drive lots of cars

When you are learning a new skill, you are most comfortableA Watching what the tutor is doing

B Talking it through with the tutor

C Giving it a try yourself (work it out as you go)

When you concentrate you most oftenA Focus on the words/pictures in front of you

B Discuss the issue and possible solutions in your headMainly C’s – Your preferred learning style may be KINAESTHETICYou will learn best when you're moving around. You will remember things best when you've done them (rather than just read about them). You may have trouble with spelling. You learn best when you can move around, you can work through problems physically, when you can use models, games and role play etc. and think over what you’ve learned whilst doing something else like swimming etc.

C Move around a lot, pick up/hold thingsYou remember things best byA Writing notes or keeping printed details

B Saying them aloud or repeating key points in your head

C Doing and practising the activity

Having met someone new, you are most likely to rememberA Faces

B Names

C Things you have said and done

This exercise is used as a guide only. Your interviewer will talk through your results with you and give you information on how to investigate your learning styles further.

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SECTION 5: ABOUT YOUR EMPLOYMENT

Employment Status Please indicate your current employment status and follow the instructions

I am registered as unemployed at Job Centre Plus (JCP) local office ___________________ (complete Part A) I am unemployed, looking for work but not registered with Job Centre Plus (JCP) (complete Part A)

I am in paid employment/self employment (complete B and C)

Part AIf you are unemployed or registered as unemployed with Job Centre Plus please complete this section

What state benefit are you receiving? (BSI)

Job Seekers Allowance (JSA) or NI credits Employment Support Allowance in Work Related Activity Group (ESA WRAG) Universal Credits Other (please state) __________________________________________ None

How long have you been unemployed/registered as unemployed with JCP? (LOU)

Less than 6 mths 6-11 mths 12-23 mths 24-35 mths 3 years or more

Are you taking part in a JCP ‘Work Programme’? Yes No If Yes, please state the training provider name: ________________________________________

Are you doing any paid work, volunteering in a company, or attending an unpaid work placement? Yes No If Yes, please give placement details in the ‘Current Employer/Placement Details’ section below (Part C)

Part BIf you are in paid employment please indicate the type of employment

I am employed by the company detailed below (Part C) and have a Permanent contract of employmentPlease tick one: I am in secure employment or I am threatened with redundancy

I am employed by the company detailed below (Part C) and have a Temporary contract of employment.

My contract end date is: / /

I am Self Employed/Sole Trader (since ...................mth/yr) and registered with the HM Revenue and Customs

I am employed by an Agency on a long term assignment to the company detailed below (Part C).

My contract end date is: / /

Part C Current Employer / Placement Details Company Name What is your Job Title?

CENTRAL CAFÉ CAFÉ ASSISTANTCompany Address

CENTRAL ROAD, WOLVERHAMPTONWho do you report to (name)?

JAMES ROGERS

Postcode W V 1 2 2 R R

Please indicate the length of employment in this company (LOE) or confirm your non-employed status

3 mths or less 4 to 6 mths 7 to 12 mths 13 mths to 35 mths 3 yrs or more OR Not employed

Company Telephone Number Company E-mail 01902 713363 CENTRALCAFE@GMAIL.COMDays you work Pattern of Hours MONDAY TO FRIDAY BETWEEN 10.00 TO 4.00 (also do late

shift)Number of hours you work per week (do not include overtime) 25Describe the main aspects of your job roleCUSTOMER SERVICE, FOOD PREPARATION AND DISPLAY, STOCK CONTROL, ORDERING GOODS, TILL OPERATION ETC.

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Employment HistoryWe require your employment history for the last 3 years. Complete this section if: You have worked at your current Company for LESS THAN 3 years (as indicated in Part C) You have been unemployed for LESS THAN 3 years (as indicated in Part A)

Please supply the details of your previous employers and/or periods of unemployment during the last 3 years

Company Name (or state unemployed) Job Title (if employed)Dates of

Employment/Service/unemployment (from and to)

BIRTHDAYSQUEEN SQUAREWOLVERHAMPTON

SALES ASSISTANT OCTOBER 2005 TO JANUARY 2016

SECTION 6: ADDITIONAL INFORMATION What are your hobbies/interests?READING ,MUSIC, GARDENING AND WALKING THE DOGS

Are you legally entitled to work in the UK? (We are legally obliged to seek this information under the Asylum and Immigration Act 1996, and you may be asked for proof of this) YES

Do you have any other information you wish to declare that may affect the type of environment you work in or training/work you can undertake (e.g. criminal records, behavioural issues)? NOPlease see notes on Safeguarding

If YES, please give brief details

Equality and Diversity: We strive to offer equality of opportunity and as part of our policy we monitor applications. Our aim is to ensure applicants are not discriminated against, either directly or indirectly. We value your background and experiences and we aim to meet your needs and expectations wherever possible. Our aim is to create a learning environment which reflects, respects and values diversity.

Safeguarding: We are committed to fulfilling our responsibilities and promoting the welfare of all learners. Please help us by providing all information that may affect you and those around you. Where we are responsible for placing you with a suitable employer, you may be required to obtain necessary DBS checks where you will be working with children or vulnerable adults. This may include the disclosure of criminal offences that have been ‘spent’.

Data Protection: We are registered under the Data Protection Act and as required by that legislation, we follow strict handling and security procedures in the storage and disclosure of information you have given us to prevent unauthorised access or misuse. The information held on your Personal Learning Record (where available) will be used to help us provide you with information, advice and guidance, unless you indicate otherwise. If you need more information about this record please speak to your provider contact or visit the National Careers Service website. Should you start a funded programme, the information on this Form will be used as per the statement below and you will be asked to indicate your preferences in how your information is used.

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This activity is part-financed by the European

Union through the European Social Fund (ESF). ESF supports

activities to extend employment opportunities

and develop a skilled workforce.

I confirm that all of the information on this form is correct and I declare that I have correctly identified my employment status and my prior qualifications. I understand that if I have declared false or incomplete information the Provider may take action against me to reclaim the tuition fees and any support costs provided.

Learner signature: _____________________ Date: 01 / 08 / 16

How We Use Your Personal InformationThe personal information you provide is passed to the Skills Funding Agency, and the Department for Business, Innovation and Skills. Where necessary it is also shared with the Department for Education, including the Education Funding Agency. The information is used for the exercise of functions of these government departments and to meet statutory responsibilities, including under the Apprenticeships, Skills, Children and Learning Act 2009, and to create and maintain a unique learner number (ULN) and a personal learning record (PLR). The information you provide may be shared with other organisations for education, training, employment and well-being related purposes, including for research. You may be contacted after you have completed your programme of learning to establish whether you have entered employment or gone onto further training or education. You may be contacted by the English European Social Fund (ESF) Managing Authority, or its agents, to carry out research and evaluation to inform the effectiveness of the programme.Further information about use of and access to your personal data, and details of organisations with whom we regularly share data are available at: https://www.gov.uk/government/publications/sfa-privacy-notice

AExample

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