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Course*

Course Title*

Name*

Surname*

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Ethnicity*

Do you have a disability?*

Please identify if you have any specific requirements or need access to particular facilities to attend the course*

Is your role*

Faith / Denomination*

Name of Trust*

Year of Appointment to Trust*

Address 1*

Address 2*

Address 3*

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Employer / Organisation Purchase Order No

You may be required to supply us with a Purchase Order Number by your trust/organisation prior to invoicing

Employer / Organisation Finance Address*

Finance e-mail address*

Finance contact telephone number*

How did you first hear about this programme?*

St Padarn's Institute Cardiff, 54 Cardiff Road, Llandaff. Cardiff CF5 2YJ

02920 563379