Adlerian Society of Wales - Adlerian Counselling Application Form

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Adlerian Certificate Application Form

1. Personal Details:

Surname/Family Name:	Forename(s) (in full):
Previous Surname/Family Name:	Date of Birth: DD/MM/YY
Gender: M/F	Marital Status:
Occupation:

Permanent Address:

Address 1:	Address 2:
City/Town:	County/Province:
Post Code:
Telephone Number (including area code):	Fax Number (including area code):
E-Mail Address:

Correspondence Address (if different):

Address 1:	Address 2:
City/Town:	County/Province:
Post Code:
Telephone Number (including area code):	Fax Number (including area code):
E-Mail Address:

Country of domicile:	Nationality:
Ethnic Origin:	Are you disabled?:
Are you in receipt of disability allowance?:	What is the nature of your disability?: (if applicable)

Do you have any criminal convictions?:

2. Proposed Programme of Study:

Title of course: e.g. Certificate /Diploma in Adlerian Counselling: Please enter details here.

3. Special Needs:

Special needs or support required as a consequence of any disability or medical condition stated in section 1: Please enter details here.
4. Your Education:

QUALIFICATIONS COMPLETED. Examinations or assessments (including core/key skills) for which results are known, including those failed:
Examination/Assessment Centre number(s) and name(s): Please enter details here.
Examination/Award			Subject/Module/Unit/ Component:	Level	Result/Grade/Mark
Month:	Year:	Examining Body:	Subject/Module/Unit/ Component:	Level	Result/Grade/Mark

QUALIFICATIONS NOT YET COMPLETED. Examinations or assessments (including core/key skills) to be completed or results not yet published:
Examination/Assessment Centre number(s) and name(s): Please enter details here.
Examination/Award			Subject/Module/Unit/ Component:	Level	Result/Grade/Mark
Month:	Year:	Examining Body:	Subject/Module/Unit/ Component:	Level	Result/Grade/Mark

5. DETAILS OF PAID EMPLOYMENT:

Names and addresses of recent employers:
Name and address: Please enter details here. Nature of work: Please enter details here.
From:		To:		Part Time/Full Time
Month:	Year:	Month:	Year:

Names and addresses of recent employers, Continued:
Name and address: Please enter details here. Nature of work: Please enter details here.
From:		To:		Part Time/Full Time
Month:	Year:	Month:	Year:

6. DETAILS OF UNPAID EMPLOYMENT:

Names and addresses of recent employers:
Name and address: Please enter details here. Nature of work: Please enter details here.
From:		To:		Part Time/Full Time
Month:	Year:	Month:	Year:

Names and addresses of recent employers, Continued:
Name and address: Please enter details here. Nature of work: Please enter details here.
From:		To:		Part Time/Full Time
Month:	Year:	Month:	Year:

7. SUPPLEMENTARY INFORMATION:

Please use this space to add information that is relevant to your application:

Supplementary Information:

8. DECLARATION:

I confirm that the information provided on this application form is true, complete and accurate, and that no information requested or other material information has been omitted. I understand that the College reserves the right to establish the authenticity of my application and that it reserves the right to cancel my application if it transpires that false information has been provided.
Signature of applicant:	Date: DD/MM/YY

Once you have submitted this form please click on your browsers back button to return to this page and be able to navigate through the rest of the web-site. Thank you for your application. We look forward to hearing from you in due course.

Please note that we're unable to process your counselling application without your name, address and telephone number(s).