ILM Qualification

Candidate Registration Form

Personal Information
Name (as required on
certificate):
Gender
: Date of Birth:
Ethnic origin code enter letter (see
notes below 1.):
Do you consider yourself to have a disability? Enter
letter*(see notes below 2.)
Preferred email
address:
Home Address
(The ILM like to have this in case you change company/organisation, so they can still trace you.)

Line 1

Line 2

Postcode
Company/organisation
name:
Company/organisation
address:

Preferred Contact Number:

Please turn page

Notes
QA & ILM are committed to equal opportunities for all regardless of race, colour, ethnic or national origin or
disability. Gender and date of birth are mandatory requirements.

1. Ethnic Origin
White Asian or Asian British
A British H Indian
B Irish J Pakistani
C Any other White background K Bangladeshi
L Any other Asian background
Mixed
D White and Black Caribbean Black or Black British
E White and Black African M Caribbean
F White and Asian N African
G Any other mixed background P Any other Black background

Other Ethnic Groups

R Chinese
S Any other ethnic group
2. Disability
P = non-disabled
Q = disabled
*A disability is defined as any physical or sensory disability, learning difficulty or mental health problem, which
has a substantial and long-term effect on a persons ability to carry out day-to-day activities.

Information will be used in accordance with the ILM and QA privacy and equal opportunity policies and will not
be used for any purpose other than in connection with this qualification.

Specific Requirements

Please indicate any additional support you may require throughout the programme. This
may include assistance with:
Work based assignments

Access to the training venue

Listening and participation during the face to face modules

Is there any additional information that you feel QA should be aware of?

I confirm that to the best of my knowledge, the information above is correct. If anything
changes that may affect my ability to carry out training related activities safely during my
training with QA, I will notify them accordingly.

Signed by learner

Name (BLOCK
CAPITALS)

Date

Thank you for completing this form.

Please return it to ILM@qa.com as soon as possible or

within 7 days of receipt. We require all forms to be
returned by the group in order for you to be registered
for your ILM qualification. We can then provide you with
your enrolment (ENR) number to gain access to
additional ILM support materials.