First Name:

Surname:

Date of Birth (dd-mm-yy):

Telephone:

E-mail:

Address:

At what age did your formal education cease? Please list any achievements or certificates awarded:

Please list any work experience and approximate periods and dates in employment starting with the most recent. Put "None" if none.

What would you hope to get from VTOS?

The following are the main areas of study on the VTOS programme in West Clare. Please indicate your preferred area of study by numbering 1-3 (your first choice should be numbered '1' and your least favourite '3')

Community Arts: # 1 2 3 Business Studies # 1 2 3 Childcare # 1 2 3

Please note that you should be in one of the following categories for at least six months when joining the programme in mid-September.

Are you in receipt of (please tick one):

Unemployment payment:

Lone Parent's Allowance

Disability Payment

Signing for Credits

Dependant of person claiming unemployment payment

Please state in months the period of time you have been (without interruption) in the unemployment category listed above: