Section 1: Candidate Details (Please print)

Title: Forename: Initial: / Surname:
How would you like your name to appear on your certificate?
Postcode: / Landline:
Address: / Mobile:
Town/City: / Email address:
County:

2ALSA Course Details

Full Course Title / Course provider:
Course Leader: / Please indicate FHEQ Level: / 4 / 5 / 6
Course Start Date: (MM/YY) / Course End Date: (MM/YY)

BDA February 2018 Registered Charity No. 289243; Company Ltd. No. 1830587 ALSA Certificate Request Form

6. Data Protection

By completing this form, you are agreeing for us to administer your BDA accreditation and where necessary share your information internally within the BDA.

From time to time we may like to send you information about our own products and services that you might be interested in, by post, telephone, email and SMS. We will not pass your information on to any organisation external to the BDA.

If you agree to being contacted in this way, please tick the relevant boxes to indicate how you would like to be contacted:

Email SMSPost Telephone

The BDA is committed to protecting your personal data please see our Privacy Policy on our website at:

7. Candidate’s Signature

By signing this form, you confirm that:

  • Payment is included and that fees are not refundable
  • You consent for us to hold your personal information as described above
  • Electronic fonts will not be accepted.

Signed: / Date:
Please note that payment is processed on receipt of application but does not imply that accreditation has been awarded - The ALSA Fee is £50
Bank transfers; British Dyslexia Association Sort Code: 20-71-06 Account: 90286141
International: IBAN GB05 BARC 2071 0690 2861 41/SWIFTBIC BARCGB22
Reference: ALSA your name
Please include a printout of payment confirmation and enclose with your application
Cheque: include with application
Credit/Debit cards: Complete and enclose the form below

Send your completed forms to Accreditation, BDA, 6a Bracknell Beeches,

Old Bracknell Lane, Bracknell RG12 7BW

Credit/Debit CardPayments (ALSA)

Please debit my account with £50.00

Card Number

X / X / X

Expiry Date

Security Number on reverse of card

Name as printed on the card
Cardholder’s signature / Date

Please note that payment will be taken on receipt of application.

BDA February 2018 Registered Charity No. 289243; Company Ltd. No. 1830587 ALSA Certificate Request Form