APPLICATION TO BECOME AN APPROVED SERVICES BROKER
To: The Director, CLEAPSS, The Gardiner Building, Brunel Science Park,
Kingston Lane, Uxbridge UB8 3PQ (e-mail steve.jones@cleapss.org.uk)
Name of applicant: (organisation)
Category of membership held:
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Teacher Training Associate Member
Overseas Associate Member
Not-for-Profit Associate Member
Commercial Associate Member
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Address:
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Postcode
Contact:
Name:
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Phone:
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Email:
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[The Applicant] [I] (delete as appropriate) wish to become an approved broker on the basis of the terms and
conditions set out in section 8 of the CLEAPSS Membership Charter, a copy of which I have received.
I understand that by signing this application form I am accepting [for and on behalf of the Applicant] (delete if not
applicable) the terms and conditions set out in section 8 of the CLEAPSS Membership Charter. I understand that, if
this application is successful, [the Applicant] [I] (delete as appropriate) will be bound by those terms and conditions
and I understand that they constitute the entire agreement in relation to all of [the Applicant's] [my] (delete as
appropriate) brokerage activities. I hereby acknowledge that in submitting this application form [the Applicant] [I]
(delete as appropriate) have not relied on any statement, promise or representation made by CLEAPSS or given on
behalf of CLEAPSS that is not set out in this application form or the terms and conditions set out in section 8 of
the CLEAPSS Membership Charter.
Signed:
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Applicant / Authorised Signatory for and on behalf of the Applicant (delete as appropriate)
Date:
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June 2015