ASSESSMENT BOOKING FORM Personal Details: First Name ____________________________________________________ Last Name _____________________________________________________ Title _________________________________________________________ Date of Birth _________________________________________________ Institution ___________________________________________________ Campus ________________________________________________________ Course ____________________________________________ FT / PT Year __________________ Year of completion ___________________ Under or Postgrad ____________________________________________ Taught/Research (if PG)________________________________________ Enrolment Number ______________________________________________ Art ID / Customer Reference Number ____________________________ LEA/Sponsor ___________________________________________________ Term Address __________________________________________________ __________________________________________________ ____________________________ Postcode_____________ Telephone ____________________________ Mobile _________________ E-mail ________________________________________________________ Home Address __________________________________________________ __________________________________________________ _____________________________ Postcode____________ Home Tel ______________________________________________________ Referred by ___________________________________________________ Academic Contact ______________________________________________ Disability Advisor ____________________________________________ Disability/condition __________________________________________ Documentary Evidence __________________________________________ Date __________________________________________________________ I confirm that all of the information I have supplied is correct as of today's date. Any information omitted from this form will be forwarded to Yorlinc Assessment Centre at the earliest possible date. Student signature ___________________________________________ Date ____________________________ Please send or fax to: Hull Assessment Centre Kyle Building University of Hull Cottingham Road Hull HU6 7RX Fax: 01482 463802 or: Lincoln Assessment Centre 50 Portland Street Lincoln LN5 7JX Fax: 01522 510399