This form may be photocopied.
Surname:		First Name:
Name for Nametag:		Staff No:
Position:		HEO Level:
School/Division/Unit:		Ext:	Email:
For the following please circle the correct answer
Are you:
	Female/Male
	Permanent/Temporary
	Full-time/Part-time
	If part-time, how many hours per week?
Do you work in a self funding unit?		Yes/No
Title of Course:		Dates:
How will this activity be of use to your work?
Applicants Signature:		Date:
Authorising Signature:
Name:		Date:
Please note that charges (if applicable) will be processed monthly as a statement and an internal transfer journal will be forwarded to Heads/Directors.
Please forward the completed form in hard copy to: Workplace Risk Management Unit T.C. Lamble Building