Back To Work,

P.O. Box 67, Basingstoke, Hants. RG24 8YG U.K.
www.backtowork.co.uk

Enquires Tel: UK 01256 351080

International Tel: +44 1256 351080

Office

Use :

N.B. Write clearly, using one form for each course applied for. Keep a copy for your records.
Places can only be confirmed on receipt of a completed application form and full course fee. Applications are only accepted at the discretion of the Course Organiser and in accordance with the Conditions Of Attendance.

PLEASE - Use your Home address to avoid mail room delays.

Course Title :

Dates :

Listed Course Location :

Your Title :

First Name :

Last Name:

Enter CLEARLY the name
to put on your certificate

Full Home Address :

County :

Post Code:

Country :

Your Professional / Therapist qualifications

Tick for Accommodation list

Please let us know where you will be staying during the course :

Local Accommodation Address & Telephone

Course Fee enclosed *:

£

If a Pro-Forma Invoice is required, please attach FULL invoicing details.

Payment Reference :

(cheque number)

Invoice/Receipt Number :

* UK courses make payment cheques to Back To Work - Send Forms and Payments to Back To Work.
* Greece courses make payment cheques to Anastasios Bratis - Send Forms and Payments to Back To Work.

The following information is only used regarding this course application :

Day Tel. No.

Home Tel No.

Mobile Tel:

I understand and agree the Conditions of Attendance

Signed

Print Name

Date

Privacy Statement : We do not pass on or give out private individuals personal information under any circumstances! You can safely quote your ex-directory number and home address to us knowing it will never end up in the hands of a home improvements company. All information is confidential and only used for providing you with a service on matters of interest to you. We do not like receiving junk mail either.