New Worx Learner Registration Form

Note: Only complete this registration form towards the end of today's session

Information about you

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* 1. Learner Details:

Name

Address

Post Code

Telephone Number

Mobile Number

E-mail

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* 2. Date of birth

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* 3. What is your gender?

Female

Male

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* 4. Are you a Peabody resident?

Yes

No