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Workers Uniting Leadership Programme: Building Power Internationally online application

Week 1: Esher Place 12 – 16 July 2010
Course code - 6952


Full name
Membership number
Yes, I have been a paying member for 6 months	Yes
Date of birth
Gender	Male Female
Are you a	Workplace rep Safety rep Learning rep Equality rep
Address
Postcode
Home telephone
Work telephone
Mobile
Email
Ethnic origin	Asian or Asian British – Bangladeshi Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British – any other Asian background Black or Black British - African Black or Black British - Caribbean Black or Black British – any other black background Chinese Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean Mixed – any other mixed background White - British White - Irish White – any other White background Other
If other, please state
Unite Regional Officer
My employer will grant me paid release to attend this union course	Yes No
Disability: Please indicate any disability or special needs that we may need to accommodate (e.g. dyslexia, hearing, impaired sight, mobility, etc.)
Dietary needs: e.g. vegetarian, vegan, gluten free, halal, etc
Employer name
Workplace address
Background History: please use the space to give a summary of your trade union history and trade union courses you have attended
Supporting Statement: please explain why you are interested in this course and why you think our global union is important
Please say how your attendance on this course will benefit the Union and the members you represent
Date