Fred

EAAS/3

December 2012

Delegate application form

PLEASE COMPLETE ALL SECTIONS OF THIS FORM IN BLOCK CAPITALS

Venue: ____________________________________ Date: ____/____/____ Course number: ____________________

Mr/Mrs/Miss/Ms Surname: _____________________________________________________________ D.o.B: ____/____/____ First name: ________________________________ Middle names(s): _________________________________________________ Home address: _____________________________________________________________________________________________ ______________________________________________________________________ Postcode: ___________________________ Home tel: ____________________________________ Work/mobile (if convenient): _____________________________________ Email: ____________________________________________________________________________________________________ What types of expeditions would you like to assess? (please tick) Walking Horse riding Cycling Water: canoeing Water: sailing Bronze Water: rowing Silver Gold At what level(s) would you like to assess?

Section A: Current DofE affiliations

Do you already have an Expedition Assessor accreditation number? Have you already been issued with an Expedition Assessor log book? Are you associated with a DofE Licensed Organisation? Yes Yes Yes No (if Yes, No._____________) No

No (please specify each one)

If Yes which one(s)? ______________________________________________________________________________________ ________________________________________________________________________________________________________ Are you a current member of an Expedition Assessor Network? Yes No If Yes please give details: Date joined: ____/____/____ Name of Network: _______________________________________________________________ Date joined: ____/____/____ Name of Network: _______________________________________________________________

Section B: Qualifications/experience

YEAR: 20____ (A) Bronze/Silver: Gold: (S)

What...