ࡱ> JLI7 1bjbjUU "P7|7|  lZZZZ8888p2ll".000000$ T"TZZ%iZ8..dAn` 0g3#z 8pt0,a|ZZZZBELFAST COGNITIVE THERAPY CENTRE Application to the: Certificate in CT Theory and Methods Course Please return to: Certificate Applications BCTC Strand House 102 Holywood Road BELFAST BT4 1NU Name ______________________________________________________ Title (Mr/Mrs/Miss/Ms) _________________________ Address _______________________________________________________________________________________________________ ____________________________________________________________ Postcode ____________________________ Phone Number _____________________________ Email _____________________________________________________ Marital Status ___________________________________________ DOB / Age __________________________________ Children (inc. ages) _____________________________________________________________________________________________ _____________________________________________ Date of Application __________________________  Education Highest Academic or Professional Qualification (Degree not necessary for Certificate)  Obtained From Date  Work Experience (Please begin with most recent) Employer  From To Nature of Duties  Any Voluntary Experience Name of Voluntary Organisation  From To Nature of Duties Contact Person and Contact Details  Motivation to Train Professionally Please give your reasons for wishing to undertake the Certificate Course at this time in your life.   Referees: Please give name and contact details of one academic and your most recent employment referee Academic:  Employment: Please outline any experience and/or qualifications as a counsellor/ therapist  Please note experience, if any, as a client  Time Commitment Trainees will be required to attend one day each week currently a Saturday - for a period of 5 months. How will you manage this time commitment?   Special Needs Do you have any disabilities or special educational needs? Yes/No (Please circle) If yes, please give brief details.   Criminal Offences By virtue of the Rehabilitation of Offenders (Exceptions) Order (NI) 1979 and because you are training for a career that requires you to be working with vulnerable adults, this application is exempt from the provisions of Article 5 of the Rehabilitation of Offenders (NI) Order 1978. Accordingly you are not entitled to withhold information about convictions, which would otherwise be considered as spent under the provisions of the 1978 Order. Failure to disclose such information could result in dismissal from the course.  Please state whether or not you have been convicted of any criminal offences YES / NO. If YES, please give details below. It should be noted that convictions for offences do not necessarily debar an applicant from obtaining a place on the course.  Where did you hear about the Certificate?   I confirm that the information I have given in this application is, to the best of my knowledge, complete and accurate.  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