Application – The Black Excellence Network

First Name

Last Name

Address

Address Line 1

City

Postcode

Phone Number

Age

Ethnicity

Current School/College/University attending

Current Level of Education

Year 12

Year 13

Undergraduate

Exams taken and grades awarded:

GCSE Grades

A-Level Grades

Degree Level

Have you completed any Observerships/Shadowing/Voluntary Work previously?

Yes

If Yes please state organisation and duration

Please confirm any physical impairments or Health Conditions

Personal Statement

I Agree that if shortlisted, I will be contacted by a member of The Black Excellence Network team for a brief telephone interview.

I Agree that if successful, I will be required to write a short report about my placement.