FLP**** Certificate in Maritime Security Management

Starts 1st December 2015

Application Form - It’s quicker to apply online which also securely accepts credit card pa

application (click the link below):

www.lloydsmaritimeacademy.com/FLP2477TT09

For security purposes you must not state your credit card number via email, mail, fax or voicemail as this ensures

never stored on our systems.

*Please delete as appropriate

If you have a VIP Code and/ or a TT code, please enter these below

VIP Code (as found on marketing material)

STEP 1: PERSONAL DETAILS

Participant's Title e.g. Mr/Mrs/Ms/Miss/Dr/Capt etc Mr

Participant's Last Name Lalsangzuala

Participant's First Name Bryan

Participant's Job Title Technician

Participant's Company Full Scale Development Corporation pvt. ltd

Participant's Address Line 1 Saikot

Participant's Address Line 2 Churachandpur, Manipur

Participant's Address Line 3 India

Participant's City Churachandpur

Participant's Postcode/Zip Code 795128

Participant's Country India

This address is my: Churachandpur, Manipur

Participant's Direct Telephone Number +91-872*******

Participant's Mobile Number +91-872*******

Participant's Fax Number

Participant's Email Address actow2@r.postjobfree.com

STEP 2: BILLING DETAILS

Who is paying for your course fees? I am personally paying

Is your address above the same as your billing address? Yes

Invoice should be sent to the attention of Me and myself only

Billing Address Line 1 saikot

Billing Address Line 2 churachandpur

Billing Address Line 3 Manipur

Billing Address City Churachandpur, manipur

Billing Address Postcode/Zip code 795128

Billing Address Country India

Billing Telephone Number +91-872*******

Billing Email Address actow2@r.postjobfree.com

STEP 3: FEES

Please select the correct payment option for Certificate in Maritime Security from the list b

FLP2477

Apply on or before 28th August 2015

Fees: £1899 + VAT= £2278.80

Apply between 29th August and 23rd

October 2015

UK Individual or UK Company or EU Individual or EU non-VAT

Fees: £1999 + VAT=£2398.80

registered company

Apply after 23rd October 2015

Fees: £2099 + VAT= £2518.80

Apply on or before 28th August 2015

Fees: £1899/$3040

(No VAT to pay)

Apply between 29th August and 23rd

EU VAT Registered Company (VAT number must be quoted October 2015

below to qualify^) or an Individual or Company outside the EU Fees: £1999/$3200

(No VAT to pay)

Apply after 23rd October 2015

Fees: £2099/$3360

(No VAT to pay)

Company VAT Number^ (needed if EU VAT registered)

**VAT is currently 20% in the UK

Which currency do you wish to be invoiced? £ GBP*

STEP 4: PAYMENT METHOD

To pay by credit card please submit your card details whilst applying online using the link at the top of this fo

telephone number below. We will contact you to collect your payment details over the telephone, or you can call the pho

invoice. For security purposes you must not state your credit card number via email, mail, fax or voicemail to ensure that y

stored on our systems.

1) Credit card - a number to call will be on the invoice or

No

please call me on the telephone number provided

2) Bank Transfer - an invoice will be emailed Yes

3) Please find enclosed cheque made payable to IIR Ltd No

STEP 5: ADDITIONAL INFORMATION

Training Manager's Title e.g.Mr/Mrs/Ms/Miss/Dr/Capt etc

Training Manager's Last Name

Training Manager's First Name

Training Manager's Job Title

Training Manager's Direct Telephone Number

Training Manager's Email Address

Approving Manager's Title e.g.Mr/Mrs/Ms/Miss/Dr/Capt etc

Approving Manager's Last Name

Approving Manager's First Name

Approving Manager's Job Title

Approving Manager's Direct Telephone Number

Approving Manager's Email Address

How did you hear about the course?

Additional Notes (if applicable)

STEP 6: DECLARATION

I have read the Lloyd's Maritime Academy distance learning course Terms & Conditions and agree to adhere to them. Term

on the course brochure or by clicking the link below.

Click here to read the Terms and Conditions

Signed lalsangzuala

If you are unable to provide an electronic signature, please make a mark in the adjacent box to show you accept the terms

conditions

Please ensure as much information as possible has been provided and the form has been signed. Only signed forms will b

Send your completed application to:

Charlene Ho

Distance Learning Training Consultant

Lloyd's Maritime Academy

KNect House, 30-32 Mortimer Street,

London

W1W 7RE

United Kingdom

Telephone: +44-20-755-*****

Fax: +44 (0-20-701*-****

Email: actow2@r.postjobfree.com

www.lloydsmaritimeacademy.com/FLP2477TT09

Lloyd's and the Lloyd's Crest are the registered trademarks of the Society incorporated by the Lloyd's Act 1871 by the name of "Lloyd's".

ement

ly accepts credit card payment with your

LP2477TT09

ax or voicemail as this ensures that your payment details are

ase enter these below

TT Code (if applicable) TT09

ILS

Corporation pvt. ltd

Churachandpur, Manipur

S

My employer is paying* A combination of both*

aritime Security from the list below:

Mark the correct option

Yes

€ EUR* $ USD

OD

ing the link at the top of this form, or provide your contact

telephone, or you can call the phone number provided on your

il, fax or voicemail to ensure that your payment details are never

Tel:

ATION

nd agree to adhere to them. Terms & Conditions can be found

22/ 10/ 2015

ox to show you accept the terms and

n signed. Only signed forms will be processed.

the name of "Lloyd's".

Contact this candidate