Apprenticeship Certificate Request Form – Automotive Industry (England)

Please complete all areas of this form in type or use capital letters in black ink. If you have any further
queries, please contact The Institute of the Motor Industry (IMI) by telephone on 01992 511521.

1. Details of Apprentice Applying for Certificate

First Name(s):

Family Name:

Name as it should
appear on certificate:
Date of Birth:
(dd/mm/yyyy) / /
Gender: Male Female

2. Details of Training Provider and Employer

Representatives from the training provider and employer must complete and sign this part of the form
to confirm that the apprentice took part in and successfully completed the apprenticeship programme.

Details of Provider: Details of Employer:

Name of Organisation: Name of Employer:

Address of Organisation: Address of Employer:

Postcode: Tel. Number: Postcode: Tel. Number:

Signature: Employer’s Signature:

Name: Name:

Position in Position in
Organisation: Organisation:
Date: Date:

3. Programme Details

Start date of apprenticeship:

(dd/mm/yyyy) / /
Completion date of apprenticeship:
(dd/mm/yyyy) / /
*Transferred from another programme: Yes No
*If a candidate has transferred in from another approved programme, they will be required to complete a
minimum of one year on this apprenticeship. In all cases, evidence of prior training must be submitted.
4. Certification Evidence
Please tick which pieces of evidence are enclosed to support this application:

Intermediate Advanced
(Level 2) (Level 3)
Copy of Technical Certificate
Copy of National Vocational Qualification (NVQ) Certificate
Copy of Application of Number Key Skill/Maths Functional Skill/Maths
GCSE (with functional content) Certificate or exemption evidence
Copy of Communication Key Skill/English Functional Skill/English GCSE
(with functional content) Certificate or exemption evidence
Copy of Information Communication Technology (ICT) Key Skill/ICT Functional
Skill/ICT GCSE (with functional content) Certificate or exemption evidence
*Copy of Declaration from training provider for delivery of Employer Rights &
Responsibilities (ERR)
Evidence of prior training
(Only needed if an apprentice has transferred from another Training Provider)
*Please note that an ERR declaration is a mandatory requirement for completing an apprenticeship application. A template
declaration form can be found on our website at http://motor.org.uk/standards-and-qualifications/certification.html
5. Framework Details
Please tick the box against the programme for which the certificate is being requested:
Framework 4 - For learners registered between 01/09/05 to 30/05/11 Level of Certificate Requested
Framework Pathway Intermediate Advanced
Level 2 Level 3
327 - Vehicle Fitting Fast-Fit
Specialist Tyre Fitting
328 - Vehicle Maintenance and Repair Light Vehicle
Heavy Vehicle
Motorcycle
Mobile Electrics
Auto Electrical
329 - Roadside Assistance and Recovery Vehicle Recovery
Roadside Assistance
330 - Vehicle Body and Paint Mechanical, Electrical & Trim
Body Repair
Body Refinishing
331 - Vehicle Parts Vehicle Parts
332 - Vehicle Sales Vehicle Sales

6. Declaration from Apprentice Applying for Certificate

I certify that the details listed in this application are correct. I enclose the supporting evidence stated in
section 4 above together with the certificate fee of £25.

Signed:

Name: Date: / /
If your training provider is making a claim
on your behalf, please sign here:
*The certificates will be sent to the training provider whose details appear above in section 2 unless otherwise
instructed.

Please return this completed form along with relevant evidence to:

The IMI
Fanshaws
Brickendon
Hertfordshire
SG13 8PQ
DATA PROTECTION ACT 1998 (THE "ACT")

The information provided in this form will be held by The Institute of the Motor Industry (IMI) securely on a database and/or in hard
(paper) copy and may be used to contact the apprentice, the training provider and the employer either by post, telephone, e-mail or
fax:

with information on any products or services which we think may be of interest

for marketing, direct marketing and or market research
for the maintenance of database records

No personal data will be sold or leased to any third party.

It is important that the information you (the apprentice, the training provider and/or the employer) provide is accurate and that you
notify us of any changes to the information provided as soon as possible. You are entitled to receive a copy of the information we
hold about you for a fee (currently £10). If at any point in time you no longer wish to be contacted by the IMI in relation to the
above you may notify us in writing at The IMI, Fanshaws, Brickendon, Hertfordshire, SG13 8PQ.

If you (the apprentice, the training provider and/or the employer) do not wish to be contacted please tick the relevant boxes below:

I (the apprentice) do not wish to be contacted

I (the training provider) do not wish to be contacted
I (the employer) do not wish to be contacted

Additional Information - Ethnic Monitoring

The IMI are committed to the promotion and monitoring of equal opportunities within the Automotive Industry and would be grateful
if you (the apprentice) could take the time to complete the following questionnaire.

To complete this information, please tick the appropriate box to indicate your cultural background:

White: British Irish

Other White Background If other, please specify ____________________________
Mixed: White and Black White and Black African
Caribbean
White and Asian If other, please specify ____________________________
Asian or Asian British: Indian Pakistani
Bangladeshi If other, please specify ____________________________
Black or Black British: Caribbean African
If other, please specify ____________________________
Chinese: Chinese If other, please specify ____________________________
Other ethnic group: Please specify ________________________________________________

Additional Information - Apprentice Status

To provide statistical analysis which supports the promotion of Apprenticeship programmes, we would be grateful if you (the
apprentice) could supply the following information:

Employed status Unemployed Status

If employed, then please indicate below the size of the employing organisation (number of employees):

Up to 50 Up to 250 250 and above

Additional Information

Under the Data Protection Act 1998, the additional information provided above will be held on a secure database and is for
statistical purposes only. The apprentice will not be identified in connection with this information and will remain anonymous. If you
should have any queries in relation to the supply and use of the following information, please contact The IMI.