Your Address?

*House Name *House Number
*Flat Number *Street Address
*Town/City *County
*Postcode (Example: NG2 3HX)

Your Phone Numbers?

*Day Time Number Area Code
*Evening Number Area Code
Mobile Number

Please state which course along with your area of choice?

Select which course you wish to apply for? Click here to select the course of your choice? Higher Diploma in Counselling (Level 5) Advanced Diploma in Counselling (level 3) Intro/Certificate in Counselling (Level 2) ADVANCED MODULES AVAILABLE: Working with Trauma Cognitive Theory Working with Children Psychodynamic Counselling Humanistic Theory Transactional Analysis Working With Supervision Working with Couples Counselling in Organisations Brief Therapy Dungannon Cookstown Omagh Newry

Important information about you!

*Qualifications Date Obtained.

Please Give Details of any other training, qualifications courses including seminars meetings and memberships you feel is relevant to your application.

*Referee *Please give details of one Referee (references will only be taken up if you are offered a place in training. Referees should normally be a present employer and/or someone who has knowledge of your academic abilities. Neither referee should be a relative or a friend please include an address and telephone number for each referee.
Please state why you feel this course of study would best suit you.
Please use the space below if there is anything further you wish to add in support of your application.

Other information!

My perceived religious affiliation is:

Catholic Protestant Other

My sex is:

Male Female

My marital status is:

Married Single Other

My family status is:

No caring responsibilities Care for other relative
Care for children Other

Disability:

Do you consider yourself to have a disability? Yes No If yes what is the nature of your disability? Please explain your disability to us... Before proceeding with your application, please ensure you have read the declaration below.

Before proceeding with your application, please ensure you have read the declaration below. Policy AGREEMENT You have read the terms and conditions setting out the agreement with JMC Counselling & Training and, if your application is accepted, you agree to be bound by these terms and conditions, as amended from time to time. You are over 18 years of age. YOUR INFORMATION: Important please read 'use of information' (section 1 of the Agreement) which sets out how your information will be used. JMC Counselling & Training will retain information provided by you on computer. By signing this application, you agree that information about you may be used like this, regardless of whether or not your application is accepted. I consent to JMC Counselling & training processing this information on this form for administrative purposes including consideration of my application but only insofar as it is permitted to do so within the constraints imposed by the Data Protection Act 1998. Data will be collected and processed with the highest degree of confidentiality. The information I have provided on this form is accurate and true. If you agree to the declaration and services offered by JMC Counselling & Training please tick this box.