Peak Management Services Ltd Registration Form If you are an existing CMI or ILM member please state Institute

membership number and whether CMI or ILM: Surname/Family name (Please show as youd like to appear on your certificate : !"aib Forename/Given name (Please show as youd like to appear on your certificate : Madhia #itle (Mr$ Mrs$ Miss% Ms$ &r etc : miss Male'(emale: female &ate of )irth (necessary for web access : *+',*'*--. Contact address: /* 0akwood road 1ast )room 2otherham Postcode: 34, .12 Is this your home or work address5 : 6ome #elephone (6ome : ,*7,-+.,4.* #elephone (8ork : Mobile: ,7-*79,.,+, 1mail: madhia"aib:hotmail%co%uk ;ob #itle: 3outh <orkshire police cadet leader 0rganisation: 3outh <orkshire police 6ow is your course funded5 (e%g% self$ employer$ grant$ sponsor etc :

The following information is voluntary only 1thnic 0rigin

8hite 8hite$ )ritish 8hite$ Irish !ny other 8hite background Mixed 8hite or )lack Caribbean 8hite and !sian 8hite and )lack !frican !ny other Mixed background !sian or !sian )ritish Indian )angladeshi Pakistani !ny other !sian background )lack or )lack )ritish Caribbean !frican !ny other )lack background Chinese or other ethnic group Chinese !rabian !ny other Chinese background !ny other ethnic group

!re you registered as disabled5 n'a (Please state nature of disability if you wish : &o you ha=e any specific learning re>uirements5 n'a &o you ha=e particular assessment re>uirements5 ?o If yes @ please state: Following for Peak office use only a) Qualification? b) Awarding Body registered with? c) ate registered? CMI/ ILM/ Edexcel

d) !ther infor"ation#