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New Deal work experience request form

Personal details

Name:
Address:
County:
Postcode:
Telephone:
E-mail address:
Date of Birth	Day Month Year
Age:

Travel

How far would you be willing/able to travel (please list areas):

Type of work experience:

Choice 1:
Choice 2:
Choice 3:

Previous experience

Any previous experience / study / training relevant to the above:

Prepared length and mode of work experience

e.g. Are you available to work 5 days per week, 2 days per week, please give details.
Please note: you must get permission from your new deal adviser before commencing work experience.

Aids or modifications

Are there any aids or modifications you are aware of which would be required to enable you to carry out the work placement?

Any other information

e.g. disability, medical restrictions on type of work you can do, any type of work you definitely do not want to do etc:

Date of application: 04-01-2012

Data Protection Act 1998

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