bLearning HNC by bLearning: Application to Enrol
For office use only
To be completed by an individual candidate or sponsoring company, as appropriate.
LUN _____________
Please complete ALL sections of this form in BLACK INK and BLOCK CAPITALS and send original
bLearning programme Fleetwood Nautical Campus, Broadwater Fleetwood, Lancashire FY7 8JZ, United Kingdom
Please attach a photograph of yourself here
PERSONAL DETAILS Surname/Family name:
First/Given names:
Previous surname/family name (if applicable)
Title (Dr, Mr, Mrs, Miss etc)
Date of Birth
Sex (male or female):
Country of Birth
Country of permanent residence:
Nationality:
Discharge Book No:
Passport No:
ADDRESSES: Permanent home address:
Address for correspondence (if different from home address):
Postcode/Zip:
Postcode/Zip:
Tel: (home)
Tel:
Fax:
Fax:
Email:
Email:
Company Name: Contact Name: Address:
Postcode:
Country:
Telephone No:
Fax No:
E-mail address:
Are you being sponsored by your company?
National Insurance No:
Yes / No
The following questions are designed to find out about your experience.
Are you serving at sea now?
Yes / No
If ‘yes’, in what capacity?
How many years seatime do you have? Please list below, the different types of ship you have sailed on, (tanker, supply, ferry, etc): 1. 4. 7. 2.
5.
8.
3.
6.
9.
Please list below any relevant qualifications (including level) you have achieved together with any short courses you have attended, and forward copies of all with your application: Certificate Held
Level
Certificate No
Date of Issue
Certificate of Competency NVQ Marine Vessel Operations HND in Nautical Science Advanced Fire Fighting Efficient Deck Hand Elementary First Aid Fire Prevention and Fire Fighting GMDSS Medical Care on Board Ship Medical First Aid NaEST (M) NaEST (O) Personal Safety and Social Responsibilities Personal Survival Techniques Proficiency in Survival Craft and Rescue Boats Tanker Safety (Petroleum / Chemical / Gas) Applicant’s Signature:
Date:
Company Representative’s Signature:
Date: PAYMENT DETAILS
• • • •
Cheque/Bankers draft payable to Blackpool and The Fylde College By your own Credit/Debit Card over the telephone on +44 (0)1253 504746 Facilities are available to pay from your own personal bank account via a Bank transfer – full details available upon request. We do not accept Travellers Cheques or Cash. Please be aware that once you are enrolled on the HNC no refunds are available.
Please note that the responsibility for determining your seatime is a statutory matter and rests with the MCA. Matters concerning your seatime MUST be referred to the MCA in Southampton. You can contact the MCA 02380 329100