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Customer Contact Form

ADVICE for Adults
In order for this service to maintain its funding, we are required to gather certain statistical data about our clients. We would be grateful if you could supply as much information as possible. This information is completely voluntary and will adhere to the strict guidelines as set down by the Data Protection Act 1998.

  Name :       Male    

   
Aged   20-24  

    25-49  
    50+  
 
  Address :       Female          
                         
                         
                                           
  Post Code :       Disability   Yes                  
                          No            
  Tel/Mobile No:                
                                               
  Email Address:                            
                                               
Qualification Level:
Learning Status:
  In Full-Time Education

Not in Full-Time Education
How did you hear about us :
Leaflet  

Newspaper Advert
Word of mouth
Referral
Other Please Specify  
 
   
No Qualifications
p
p

       
    NVQ Level 1
GCSE D less		        
    NVQ Level 2
GCSE A-C x 5
p 		                 
    NVQ Level 3
A levels
p 		                 
    NVQ Level 4
Degree
p 		                 
NVQ Level 5
p 		   
Other
p
p
Employment:
Full time employed Non employed
Part time employed Unemployed less than 6 months
Self employed Unemployed more than 6 months
           
Ethnicity:
White – British
 Asian or Asian British – Bangladeshi
White – Irish Asian or Asian British – Other
White – Other Black or Black British – Caribbean
Mixed – White & Black Caribbean Black or Black British – African
Mixed – White & Black African Black or Black British – Other
Mixed – White & Asian Chinese
Mixed – Other Other
Asian or Asian British – Indian Prefer not to say
Asian or Asian British - Pakistani  
We would like to follow up people from time to time to see how helpful they have found our service. Would you be happy if we held on to your details and contacted you in the near future?  


  Data Protection Statement (Act 1998)
This information will be held confidentially and may be shared with other organisations for administrative, statistical and research purposes, to inform careers and other guidance agencies and to monitor progress.
I confirm that the information contained on this form is correct and that I agree to it being used in line with the Data Protection Act 1998 as outlined above.
Agree Date