Gas Commercial TPCP 1
CCGS04703ST
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| Title |
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Previous Surname
(if changed) | |
| Date of Birth * |
|
| National Insurance Number | |
| Tel. Home (including area code) * | |
| Country of Residence |
|
| Have you been a permanent resident of the UK or the EU during the whole of the last 3 years | Yes No |
| Do you consider yourself to have a disability and/or learning difficulty? | Yes No |
Disability
(Please tick all that apply). |
Visual impairment Hearing impairment Disability affecting mobility Other physical disability Other medical Condition (e.g. epilepsy, asthma) Emotional/behavioural difficulties Mental Health difficulty Temporary disability after illness (e.g. post-viral) or accident Profound complex disabilities Aspergers syndrome Multiple disabilities Other No disability
|
Learning Difficulties
(Please tick all that apply). |
Moderate learning difficulty Severe learning difficulty Dyslexia Dyscalculia Other specific learning difficulty Autism spectrum disorder Multiple learning difficulties Other No learning difficulties Not known / Not provided
|
| Will you require any alternative arrangements to assist you at initial assessment/interview? * | Yes No |
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|
I have a previous unspent criminal conviction
(excluding traffic offences) * | Yes No |
| If Yes Please give details | |
