} else {
}
Maytas Hub
5.28.9020.1
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5.28.9020.1
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Expression of Interest Form
Personal Data
Please complete this form in full. The information, and the supporting documentation you provide will enable us to review your eligibility for the Apprenticeship Programme you are applying for. The information requested is mandatory, and is required to validate and progress your application.
Title
---
Miss
Mr
Mrs
Ms
First name(s)
*
Last Name
*
Date of birth
*
National Insurance Number
*
Address Line 1
*
Address Line 2
Town
*
Postcode
*
County
---
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Humberside
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Manchester
Merseyside
Norfolk
North Yorkshire
Northamptonshire
Northumberland
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Yorkshire
Wiltshire
Worcestershire
Gender
*
---
Female
Male
Other
Preferred Pronouns
---
he/him/his/his/himself
she/her/hers/hers/herself
they/them/their/theirs/themself
fae/faer/faer/faers/faerself
ae/aer/aer/aers/aerself
e/em/eir/eirs/eirself
ey/em/eir/eirs/eirself
per/per/pers/pers/perself
ve/ver/vis/vis/verself
xe/xem/xyr/xyrs/xemself
ze/hir/hir/hirs/hirself
zie/hir/hir/hirs/hirself
Custom pronouns
Unknown/Prefer not to say
Email Address
*
Phone Number
Mobile Number
ID Upload
Do you have an Education Health Care Plan?
---
1 - Learner has an Education Health Care plan
Do you receive disability student support allowance?
---
1 - Has disabled students allowance
Do you have a disability?
---
1 - Has Difficulty/Disability
2 - No Difficulty/Disability
9 - No information provided
Health Problems
04 - Visual impairment
05 - Hearing impairment
06 - Disability affecting mobility
07 - Profound complex disabilities
08 - Social and emotional difficulties
09 - Mental health difficulty
10 - Moderate learning difficulty
11 - Severe learning difficulty
12 - Dyslexia
13 - Dyscalculia
14 - Autism spectrum disorder
15 - Asperger's syndrome
16 - Temporary disability after illness (for example post-viral) or accident
93 - Other physical disability
94 - Other specific learning difficulty (e.g. Dyspraxia)
95 - Other medical condition (for example epilepsy, asthma, diabetes)
96 - Other learning difficulty
97 - Other disability
98 - Prefer not to say
99 - Not provided
X - 01 - Emotional/behavioural difficulties
X - 02 - Multiple disabilities
X - 03 - Multiple learning difficulties
Primary Health Problem
---
04 - Vision impairment
05 - Hearing impairment
06 - Disability affecting mobility
07 - Profound complex disabilities
08 - Social and emotional difficulties
09 - Mental health difficulty
10 - Moderate learning difficulty
11 - Severe learning difficulty
12 - Dyslexia
13 - Dyscalculia
14 - Autism spectrum disorder
15 - Asperger's syndrome
16 - Temporary disability after illness (for example post-viral) or accident
17 - Speech, Language and Communication Needs
18 - Down Syndrome
93 - Other physical disability
94 - Other specific learning difficulty (e.g. Dyspraxia)
95 - Other medical condition (for example epilepsy, asthma, diabetes)
96 - Other learning difficulty
97 - Other disability
98 - Prefer not to say
99 - Not provided
X - 01 - Emotional/behavioural difficulties
X - 02 - Multiple disabilities
X - 03 - Multiple learning difficulties
Confirmation
The tick box represents your digital signature in this form. By ticking the box, you confirm the information you have provided is true and accurate
done
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