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Name*:

Contact Number*:

Postal Address*:

Postcode*:

Email address*:

Date of Birth (dd/mm/yyyy)*:

National Insurance Number:

Ethnicity* Please Select... Black or Black British White British White Other Asian or Asian British Chinese Mixed Not Known Not Provided

If yes, please select from the list*: Please Select... Visual Impairment Hearing Impairment Disability Affecting Mobility Other Physical Disability Other Medical Condition (e.g. epilepsy, asthma, diabetes) Emotional / Behavioural Difficulties Mental Health Difficulty Temporary Disability After Illness (e.g. Post Viral) Profound Complex Disabilities Aspergers Syndrome Multiple Disabilities Other No Disability Not Known / Information Not Provided

If yes, please select from the list*: Please Select... Moderate Learning Difficulty Severe Learning Difficulty Dyslexia Dyscalculia Other Specific Learning Difficulty Autism Spectrum Disorder Multiple Learning Difficulties Other No Learning Difficulty Not Known / Information Not Provided

Employment Status*: Please Select... Currently Employed Unemployed for less than 6 months Unemployed for 6 to 11 months Unemployed for 12 to 23 months Unemployed for 24 to 35 months Unemployed for 36 months or more

Please tick which benefits you are currently receiving*:

Job Seekers Allowance
Employment Support Allowance
Income Support
Incapacity Benefit
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None

If “other” please give details here*:

Job Reference you are interested in:

What would you like to discuss with us?: (please give brief details)