Forename:

Surname:


Address

E-mail


Tel


Response required by E-Mail Telephone Post

National Insurance Number

Date of Birth:   Age:

Gender: Male Female

Which Job Centre do you sign on at:

Batley Bradford Brighouse Dewsbury Guiseley Halifax Huddersfield Keighley Morley Pudsey Shipley Spen Valley Todmorden

PLEASE NOTE: You must be signing on at one of these Job Centres as the scheme is only operating in Calderdale & Kirklees, Leeds and Bradford Districts at present.

How long have you been unemployed? 0 1 2 3 4 5 6 7 8 9 9+ Years  1 2 3 4 5 6 7 8 9 10 11 12 Months

Of what Ethnic Origin are you?    Black African Black Caribbean Black Other Bangladeshi Indian Pakistani Chinese White Other

Do you require any of the following? Grants    Loans    Prince's Trust    Tools Loan
Specialist Training    Transport>

How user friendly was this form? Excellent Good Fair Poor Bad

Where did you hear about the Into Business Scheme?