​                                                    APPLICATION FORM  2021 -2022
                                                               Confidential Document 
    Course Title or Code________________________________________________________
    Name: ____________________________________________________________________
    Address:  __________________________________________________________________
   __________________________________________________________________________
   __________________________________________________________________________
   Telephone No: ______________________Date of Birth ____________________________
   Mobile No: _________________________ E-MAIL _______________________________
   Occupation ________________________________________________________________ 
  ITEC No.**___________________________
  Educational Qualifications: ____________________________________________________
  __________________________________________________________________________
  __________________________________________________________________________
  __________________________________________________________________________
  Reasons why you wish to study this course________________________________________
  __________________________________________________________________________
  __________________________________________________________________________
  __________________________________________________________________________
 
   Return by: ___________________________    (Check with college as course dates vary)
 
  Do you have any allergies? ____________________________________________________
  If Yes Please describe. _______________________________________________________
  Do you have any special needs? ________________________________________________
  If YES please describe. _______________________________________________________
 
  First-Aid Qualification: (Please tick) Yes ..........   No  ............  Date........................
 
   Declaration by Applicant
   Your Signature indicates that the information you have provided is true and that I have read, understood and agree to uphold the     terms and conditions of the IISSM
 
   SIGNED:______________________________         DATE:______________..
 
    Office Use:
    Date received:                             ______________
    Deposit received:                        ______________
    Amount outstanding:                   ______________
    Method of payment agreed:         _____________  
    Examination Fee                         ______________
     IMPORTANT
   Some course fees are linked together. If you are taking more than one course contact the college re-exact course fee,        Payment plans available 
   Contact College Director to discuss  on  087 2513154 or email:    ardlynn@yahoo.com
   Accreditation for Prior Learning.  (APL) Will be reviewed at the start of the course and students whom this may apply         will be advised to sign up a form re: same
     Revised:  September 2021