Examination Candidate Registration Form
This form is for BHI members who have not yet registered for the level of diploma qualification (Level 3, 4 or 5) at which they want to enter exam units in 2017. You can register as an exam candidate on this form. There is a separate application form for entering exam units.
You can find information on diploma qualifications and examination units, including the different levels and pathways (mentioned below) on www.bhi.co.uk.and in the Examination Handbook which you can download on our website.
Please print, complete and send this form to Examinations, BHI, Upton Hall, Newark, Nottinghamshire, NG23 5TE, United Kingdom. You can also scan the completed form and email it to , but remember this is a less secure way of submitting your registration.
1. Your details
(please tick one)
☐ BHI membership number: ______
☐ I do not know my membership number
Title: ____
First name (this will eventually appear on your certificate): ______
Other initials (if required, these will eventually appear on your certificate): ______
Last name (this will eventually appear on your certificate): ______
Address: ______
Town: ______Postcode: ______
Country: ______Phone: ______
Email: ______Date of birth: ______
Gender:
☐ Male
☐ Female
Please go to the next page.
Particular assessment requirements:
(please tick where appropriate and enclose supportive information)
☐ None
☐ Physical or mental disability
☐ English as a second language
☐ Other, namely: ______
Ethnicity:
(please tick one)
☐ White British
☐ Black or Black British (Caribbean)
☐ Asian or Asian British (Indian)
☐ White (Irish)
☐ White (Other)
☐ Black or Black British (African)
☐ Black or Black (Other)
☐ Asian or Asian British (Pakistan)
☐ Asian or Asian British (Bangladeshi)
☐ Asian or Asian British (Other)
☐ Mixed - White and Black Caribbean
☐ Mixed - White and Black African
☐ Mixed – White and Black Asian
☐ Mixed – White and Black Other
☐ Chinese
☐ Other
☐ Prefer not to say
Please go to the next page.
2. Your level and pathway
Register me as an examinations candidate for:
☐ Diploma in Clock and Watch Servicing (Level 3) at £45.00
☐ Diploma in the Servicing and Repair of Clocks/Watches (Level 4) at £45.00
☐ Diploma in the Repair, Restoration and Conservation of Clocks/Watches (Level 5) at £45.00
(Levels 4 and 5 only)
I will follow the:
☐ Clock pathway
☐ Watch pathway
Please go to the next page to complete this form and give us your payment details.
3. Your payment
I will pay my registration fee of £45.00 / £90.00 / £135 (please delete as appropriate) as follows:
(please tick one and complete where necessary)
☐ I enclose a cheque in UK £ sterling made payable to ‘BHI Ltd’
☐ I want to pay with my debit card (please give card details below)
☐ I want to pay with my credit card and I understand you will add a 3% credit card surcharge (please give card details below)
Name on card: ______Card number: ______
Expires: _____ Security code (last three digits): ____
First line of the billing address: ______
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British Horological Institute Ltd Upton Hall Newark Nottinghamshire NG23 5TE United Kingdom Phone: +44(0)1636 813795 Facsimile: +44(0)1636 812258 www.bhi.co.uk
Company Registration Number: 0013 0649 VAT Registration Number: GB 598546473