Compe’ Candidate Registration Form - Ex01 to Ex10 Tr ATE ETT UoLad CNA COUNTRY {EET Ps DATE OF BIRTH DUZER Formal Electrica/Instrument Qualifications and/or other Relevant Craftpersons Certification Qualifications: Date Awarded Brief History of Employment in Electrical Industry and/or Hazardous Area Environments Date Employer Experience Gained Requirement: Please tick the next section as appropriate | wish to be trained and assessed or assessed only in the following units EXO1 EXO2, EX03, EXO4 EXOS, EX06, EXO7, EX08, EXO9, EX10. Sprains [Please tick os appropriate) Teerlfy hat oll the above information is true and thatl am, or until very recently have been, employed as a qualified electrotechnical craftsperson. OR \ certify that | om not an electrotechnical craftsperson. (CSNV Compéx certificate issued) ITL904 Rev7 07/16 Page 1 of 2eclaration of Acceptance of Scheme Requirements In signing this registration form the applicant agrees to: ‘Comply with the requirements for certification including those in the candidate code of conduct {JTL920}. (Only make claims regarding certification that are within the scope for which certification has been granted, © Not use the certification in such a manner as to bring the certification body (JT Limited) into disrepute, and not to make any statement regarding the certification which the certification body (JT Limited) may consider misleading or unauthorised © Discontinue the use of all claims to certification that contains any reference to the certification body (JT Limited) where certification has expired, been suspended or withdrawn. Any certificates issued by the certification body (JT Limited) shall be returned. + Notuse the certificate in a misleading manner. * Inform the certification body (T Limited}, without delay, of matters that can affect their capability to continue to fulfill the certification requirements. * Commit not to release confidential examination materiak or participate in fraudulent testking practices * Provide the Licenced Centre with evidence of qualifications/original certification/craftpersons certificates as recorded on this Candidate Registration form * Declare (if they feel necessary) any special needs that they feel must be taken into consideration during the certification process. + [understand that the processing of my personal details and achievements will toke place and that this will be in accordance with the Data Protection Act 1998. | certify that to the best of my knowledge, the information provided on this registration form is correct. | give my permission fo JT Limited for my photograph to be used for the purposes of the CompEx ID Card. Images will be held on record for a period of six years. Signatur Date: Print Name NOTE: PLEASE RETURN THIS FORM TO THE CENTRE YOU WILL BE ATTENDING Ihave checked the above details and verify that they are complete ond accurate and that | have seen evidence of identification and original certification /written evidence confirming electrotechnical crafipersons status (A ceriticate of Core Competence willbe issued. Please fick box) Ihave checked the above details but the candidate has foiled to supply original evidence confirming electrotechnical crafipersons status. (A Core Competency CSNV Cerificate will be issued — Please fck bo») Instructor/Assessor Signature: Print Nam Date: Centre Details IT Limited CompEx, Third Floor, Redwither Tower, Redwither Business Park, Wrexham, LLI3 9XT ITL904 Rev7 07/16 Page 2 of 2