Client Record Sheet - PDF by mzq79210

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									                      Client Record Sheet
Section A - CONTACT INFORMATION
Name:

Address:

                                                                                                              Postcode:

Tel:                                                                          Email:

Section B - PERSONAL INFORMATION
Date of Birth:                                                 National Insurance No:
Date of Birth and National Insurance No. are purely a requirement for ESF Audit and will not be disclosed to third parties.

Age Range:       J    Under 25           J       25-29             J       30-39        J         40-49        J        50-64          J      65+



J White British                 J                              J                              J                                 J
Ethnicity:


J MixedCaribbean                J                              J                              J                                 J
                                    White Irish                       White Other                   Chinese                         Mixed white & Asian
        white &                     Mixed white &                     Black or Black                Black or Black                  Black or Black


J Asian or Asian                J                              J                              J                                 J
  Black                             Black African                     British - Caribbean           British - African               British - other
                                    Asian or Asian                    Asian or Asian                Asian or Asian                  Mixed Other


J Not known                     J
  British-Indian                    British-Pakistani                 British-Bangladeshi           British - other
                                    Other, please specify:



J Adult                         J                              J
Dependents:
                                    Pre School Children               School Age Children

Have problems with care for dependents stopped you getting to work or training?               Yes    J            No    J

J English language              J                              J                              J                                 J
Additional Information:
          as a                      Mental Heath                      Do you require help           Returning to the                Recently made


J Homeless                      J                              J                              J                                 J
  second                            Problems                          with Basic Skills?            labour market                   redundant


J Dyslexic                      J                              J
                                    Live in a rural area              Care responsibilities         Ex-offender                     Refugee
                                    Disability                        Single parent

                                                                                                                                J
J GCSE Maths                    J                              J                              J                                 J
Qualifications: Please tick all boxes that apply (or their equivalent level if not listed below).                                   None / Entry Level


J NVQ Level 1                   J                              J                              J                                 J
                                    GCSE English                      A/AS-Level                    Degree                          Further Degree
                                    NVQ Level 2                       NVQ Level 3                   NVQ Level 4                     NVQ Level 5

  Section C - EMPLOYMENT STATUS


  J Pre-Start (Planning)            J Part Time                                     J                        J                      J Employed
  Self Employed (running your own business)                                         Employed (working for someone else)



                                    J Full Time
                                                                                         Employed                 Employed
                                                                                         Full Time                Part Time           Part Time
                                                                                         (>30 hrs)                (>16 hrs)               (<16 hrs)
              Go to Section E                            Go to Section D                                                               Go to Section D


  Education                                                                         Other

  J Full Time                       J Part Time                                     J    Claiming
                                                                                         Benefits
                                                                                                             J    Unwaged           J Unemployed
                                                     Go to Section F                                       Fill in question below and got to Section F




J Under 6 months                J                              J                              J                                 J
If you are currently unemployed or taking time out of the labour market, for how long?:
                                    7 to 12 months                    13 to 24 months               25 to 36 months                 Over 37 months
Section D - BUSINESS INFORMATION


                              J                            J                         J                            J
Company Name:



                              J                            J                         J                            J
Type of Business:                 Sole Trader                   Partnership               Limited Company             Charity



                                                                                                                                  J        J
                                  Social Enterprise             Co-operative              Voluntary Sector            Community Group

Number of people employed:                             Is your organisation more than 25% owned by another organisation? Yes          No



J Under £5000                 J                            J                         J                            J
Annual Turnover:
                                  £5001 - £10000                £10001 – £25000           £25001 - £60000             £60001 plus


In order to be eligible for you to receive this training, the business for whom you work needs to be EITHER micro, small or
medium as defined below, AND fit either the turnover or the balance sheet definitions which apply to that size.


                 J Micro: employs less than 10 people; and either has less than € 2m turnover or less than € 2m balance sheet
Please don’t hesitate to call us on 0800 012 1365 if you are not sure how to complete this section.


                 J Small: employs less than 50 people; and either has less than € 10m turnover or less than € 10m balance sheet
Size of Business:



                 J Medium: employs less than 250 people; and either has less than € 40m turnover or less than € 27m balance sheet
                 J Large business: employs more than 250 people; and either has more than € 40m turnover or more than € 27m balance sheet
                          J Start Up - Trading for less than one year              J New - Trading for between one and five years
                          J Established - Trading for over five years
Age of Business:



Has your business received any grants or state aid in the last three years?        Yes J          No J
                                                                                   If yes please complete the section below
Funding provider:                                                                                             Date:

Amount:                           Reason:


Section E - BUSINESS SECTOR
J Professional &              J   Arts, sport              J    Media &              J    Catering &              J   Health & social


J Agriculture, forestry J                                  J                         J                            J
    business services             & recreation                  creative services         accommodation               care services
                                  Retail, hire                  Transport &               Mining, energy              IT & telecom


J Manufacturing               J                            J                         J                            J
    & fishing                     & repair                      distribution              & utilities                 services
                                  Wholesale                     Education                 Personal services           Construction


Section F - HOW YOU HEARD ABOUT ENTERPRISING WOMEN

J                                                                              J
How did you hear about Enterprising Women?


J                                                                              J
     Leaflet, location?                                                             Event, where?



                                    J                               J                         J                         J
     Press, which paper?                                                            Word of Mouth?



                                    J                               J                         J
     Did you hear about us from           Prowess                       Incredit                     YTKO                       WEETU



J
                                          Norfolk Network               WiRE                         University of Bedfordshire



                                                       J            J
     Other, please specify:
Do you have easy access to the internet?         Yes           No

I understand this project is co-funded by the European Social Fund.
Clients Signature:                                                                        Date:

J and your detailshave yourbe disclosedto keepthird parties.on addition, only anonymised datais required byfor projectProtection to
  Please can we
                   will not
                            permission
                                        to any
                                               your details our database? This permission
                                                            In                                will be used
                                                                                                            the Data
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    EEDA and we are registered with the DPA. (tick box)

Please return completed form to:
Project Manager, Enterprising Women Programme, St Faith’s House, Mountergate, Norwich NR1 1PY • Fax: 01603 66 33 40

								
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