QCD Student Application Form

Title

Forename

Surname

D.O.B

Gender

Address

Postcode

Email Address (please supply your personal email address and NOT a university or an employer email address)

Telephone Number

QCD Course Centre

Study Type

Employer Name & Address

Postcode

Ethnic Origiin

Do you consider that you have a disability?

If yes, please state below

Student Membership Payment

QCD Registration Payment

Will you be paying in instalments?N/A - My employer/University are paying
No - 1 Instalments totalling £365
Yes - 2 Instalments totalling £375

Declaration

1. I confirm that the information i have given is correct

2. I have seen the CDI Code of Ethics and confirm I will abide by it

3. I agree that in the event that the Institute is wound up that I will contribute a sum not exceeding one pound sterling.

I confirm that I have read and agree to the above declaration

Submit

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