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50 not out! - Your details

If you are aged 50 or over and unemployed, or at risk of becoming unemployed, or currently receiving incapacity benefit, and you are looking for work, this is for you!

Adult Community Learning, Essex Libraries and the East of England Development Agency are working in partnership to provide FREE Information and Advice to support you in getting back to work. Just ask for more details from a member of library staff.

Information about you:

Title:	Please select ... Ms Miss Mrs Mr Other , if Other, please state:
First Name:*
Surname:*
Address:
Post code:*
Contact Day: Evening:* Mobile: Email address:
How do you prefer* to be contacted?  Please select ... by email by telephone - day by telephone - evening by telephone - mobile

Gender:	male   female
Are you age 50 plus?*	Yes  No
If you selected No, we may still be able to support you.
Are you currently unemployed?	Yes  No
Are you at risk of being unemployed?*	Yes  No
Are you currently receiving incapacity benefit?*	Yes  No
Would you consider yourself to have a physical, sensory or learning impairment or disability?*	Yes  No

Ethnic Origin: This information is requested for Equal Opportunities monitoring. Please tick the box that applies to you. Asian or Asian British Please select ... Bangladeshi Indian Pakistani Any other Asian background Black or Black British Please select ... African Caribbean Any other Black background Mixed Please select ... White and Asian White and Black African White and Black Caribbean Any other Mixed background White Please select ... British Irish Any other White background Chinese Any other
Your qualifications:
Do you have a qualification?	Yes  No
If you have answered Yes, please state your highest qualification: Please select ... No qualifications Entry Level Level 1 Level 2 Level 3 Level 4 Level 5 Level Not Known   or
Which Library are you visiting?*	Please select ... Braintree Brentwood Chelmsford Harlow Loughton Maldon Other
Other library locations:
Where did you hear about the project?

Appointment:
Would you like to book an information and advice appointment with our specialist advisor?	Yes  No;
If you select Yes we will contact you as soon as possible. *) We may choose to use your other contact options, if available.

Thank you for taking the time to fill in this questionnaire. The information you have provided is treated as confidential and all partners are registered under the Data Protection Act 1998.

Although this project is based on a small budget funding we endeavor to contact you with in two working days.

 

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