REGISTRATION FORM
Background Information
First Name:
*
Surname:
*
Date of Birth [dd/mm/yy]:
Who referred you to CXC?
Gender:
Male
Female
Private Email:
*
Repeat Private Email Address:
*
Work Email :
*
Home Phone:
*
Work Phone:
Mobile Phone:
*
Fax:
UK Address:
Street
Area
Town/City
PostalCode
Nationality:
National Insurance No.:
Employment Information
Type of visa that allows you to legally work in the UK:
Working Holiday
EU Passport
Work Permit
Ancestry
HSMP
Right of Abode
Employment Industry:
IT
Finance
Engineering
Teaching
Construction
Surveying
Marketing
Other
Does your employment position involve laying / installing / repairing cables?
(For Insurance Purposes)
Yes
No
Do you hold a CIS Card?
(This only applies to individuals working in the construction industry)
Yes
No
Employer / Agency Name:
Employer / Agency Fax:
Contact Name:
Contact Email:
Contact Phone:
Rate of Pay:
per
Hour
Day
Bank Account Information
Account Holder's Name:
Account Number:
Sort Code:
Bank Name:
Bank Address:
Street
Area
Town/City
PostalCode
Roll Number:
(If builidng society)
Overseas Bank Account Information:
Account Holder's Name:
Account Number / IBAN:
Bank Name:
BSB / SWIFT:
Bank Address:
Street
Area
Town/City
PostalCode
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.
