Registration

REGISTRATION FORM

Background Information

First Name:

Surname:

Date of Birth [dd/mm/yy]:

Who referred you to CXC?

Gender:

Private Email:

Repeat Private Email Address:

Work Email :

Home Phone:

Work Phone:

Mobile Phone:

Fax:

Arrival Date[mm/dd/YYYY]

Address:

Street

Area

Town/City

PostalCode

Nationality:

Employment Information

Type of visa that allows you to legally work in the UK:

Employment Industry:

Does your employment position involve laying / installing / repairing cables?
(For Insurance Purposes)

Yes No

I confirm that I have not previously been the subject of a claim that would otherwise be covered by the Professional Indemnity Insurance Policy and that after reasonable enquiry I am not aware of any claims or circumstances that might give rise to a claim under the Professional Indemnity Policy.