| Women Inspiring Women Application Form |
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| HAVE YOU EVER BEEN KNOWN BY ANY OTHER NAME(S)? : |
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If Yes,Give Full Details : |
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| ARE YOU REGISTERED DISABLED ? |
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IF YES GIVE DETAILS OF DISABILITY |
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| DO YOU HAVE A MEDICAL CONDITION OF WHICH WE SHOULD BE AWARE ( IE:DIABETES, EPILEPSY, ETC): |
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IF "YES "GIVE DETAILS: |
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| GIVE DETAILS OF ALL MEDICATION YOU TAKE ON A REGULAR BASIS (WHETHER PRESCRIPTION AND NON-PRISCRIPTION) |
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DETAILS OF NEXT OF KIN ( WHO SHOULD BE CONTACTED IN CASE OF EMERGENCY ) |
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| RELATIONSHIP TO YOU(MOTHER,FATHER,SISTER,BROTHER,FRIEND NEIGHBOUR ETC): |
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STYLE AND SUBJECT(IE GCSC,CSE ETC :) |
GRADE |
STYLE AND SUBJECT(IE GCSC,CSE ETC :) |
GRADE |
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FURTHER EDUCATION (SEE NOTE 1 BELOW) |
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NAMES, ADDERESSES AND SUBJECT(S)TAKEN |
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FROM |
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TO |
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STYLE AND SUBJECT (EG NVQ,DEGREE, ETC) |
GRADE |
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STYLE AND SUBJECT (EG NVQ,DEGREE, ETC) |
GRADE |
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NOTE 1 : Include all courses and studies undertaken after full time education ceased ,as well as any in-house courses given by employers
or one day release
please countinue on separate sheet of paper if necessary. |
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| GIVE THE NAME AND ADDRESS OF TWO PEOPLE WHO CAN GIVE YOU A CHARACTER (THESE SHOULD NOT BE RELATIVES) |
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Job AND THE NAME OF THE COMPANY YOU WORK FOR |
FROM |
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ANY OTHER COMMENTS |
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PLEASE GIVE THE DETAILS REGARDING YOUR CAREER ASPIRATIONS ,GOALS ETC AND ANY OTHER INFORMATION YOU FEEL IS RELEVANT TO YOU BEING PART OF THE WOMEN INSPIRING WOMEN MENTORING PROGARAMME ? |
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HAVE YOU HAD ANY CRIMINAL CONVICTION OR BEEN ARRESTED SUSPICION OF A CRIME ? THIS WILL NOT EFFECT YOUR ATTENDANCE ON YOUR PROGAMME ANY WAY |
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IF 'YES' PLEASE GIVE DETAILS |
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PLEASE READ THE FOLLOWING STATEMENT CAREFULLY BEFORE SIGNING AND DATING THE APPLICATION |
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I CONFIRM THAT THE INFORMATION AND DETAILS GIVEN IN THE APPLICATION ARE TRUE AND CORRECT AND THAT ANYTHING THAT IS LATER FOUND UNTRUE, INCORRECT, OR OMITTED CAN RESULT IN MY INSTANT DISMISSAL AND MAY LEAD TO LEGAL PROCEEDINGS BEING TAKEN WHERE APPROPRIATE. |
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