CONFIDENTIALITY AGREEMENT - Microsoft



Personal DetailsTitleSurnameFirst Name(s)Contact Address (Term time university address)House Name/No.StreetTownCountyPostcodeContact DetailsOther DetailsMobile No.Date of birthEmail addressNationalityDo you need a visa to study in the UKYES ? NO ? Employment Status I Am: (Please select 1 of the following A full time student at Birmingham City University A part-time student at Birmingham City UniversityA graduate of Birmingham City UniversityA full time student at another University A part-time student at another UniversityA graduate of another universityIf another university, is selected please enter the name of the university of which you are a full time / part time student or graduate_________________________ If you are NOT a current full-time student, please confirm that you are either:Employed orUnemployedI confirm that I have not yet started to trade (please tick)Description of Assistance Provided and the Date it was Provided2 day European Business Masters Cup (EBMC) competition run at Birmingham City University Monday 16th & Tuesday 17th January 2017Data ProtectionThe information that you provide on this form will be available to: University Project and Finance staff involved in the management of the Project including any external auditors appointed by Project staff; the regional agency, Department for Communities and Local Government (DCLG) and its auditors, and auditors appointed by the European Commission.You agree that your personal information may be used for evaluation purposes and to participate in any evaluation exercise carried out by the Funding Agency or an external consultant.Please tick here to confirm that you have read and understood the above conditions. This is a fundamental requirement for any person wishing to receive assistance through the project.□We may take pictures/videos of you as well as quotes or case studies about your experience.. I give my consent to use these (please tick).□Diversity Monitoring InformationThe project is required to provide statistical information about our beneficiaries to the Funding Body, the European Regional Development Fund (ERDF) or their agent, DCLG. In order to comply with this requirement we ask you to complete the following information. This is voluntary and the information you provide will be treated in total confidence. Thank you for your co-operation.Ethnicity□White British□White Irish□Other White Background□Black or Black British Caribbean□Black or Black British African□Other Black Background□Asian or Asian British – Indian□Asian or Asian British – Pakistani□Asian or Asian British – Bangladeshi□Chinese□Other Asian Background□Mixed White/Black Caribbean□Mixed White/Black African□Mixed White/Asian□Other Mixed Background□Other Ethnic Background□Information refusedGenderMaleFemale Do you have a disability as defined in the Equality Act 2012? If so please indicate the type of disability that you have.00 No known disability02 Blind/partially sighted03 Deaf/hearing impairment04 Wheelchair use/mobility impaired05 Personal care support06 Mental health difficulties07 An unseen disability i.e. asthma08 Multiple disabilities10 Autistic spectrum disorder11 Specific learning disability96 Not listed above97 Information refusedSignedDate ................
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