NLP Diploma Application Form
Name
Profession/Job title
Dept & Trust
Ethnicity
Address
Contact Email
Contact telephone number
Information required for ILM
registration *
Date of Birth *
Male / Female*
__ /__ / __
I would like to attend the NLP Diploma on: (Please select a pre-booked date-stated on the faculty webpage)
Date:
Venue:
I confirm by way of submitting this application form that I plan to attend the above course and have gained
study leave (if required). Once I have been confirmed a place on this course if for any reason I cannot attend, I
will inform the AHP team in the first instance giving notice prior to the date of the course.
Delegate Signature:
Date:
Line Manager / Directorate Education Lead - Please confirm the following
The applicant has agreement to be released from practice to attend & complete this course Yes / No
Please provide budget code or indicate if course is being funded from educations funds
Budget code:
Line Manager Name (please print):
Job Title:
Address:
Email:
Telephone Number:
Signature*:
Date:
Please print name and contact number of manager authorising attendance on this course
Please return completed application form to- fbu@heartofnengland.nhs.uk