Learner Registration Form

First Name

Surname

Address 1

Address 2

Town

County

Email Address

Landline No.

Date of Birth

Course Code & Title

Mobile No.

PPS No.

Gender

Are you working towards a QQI Major Award?

Course Fee

Do you have any requirements we should be aware of?

Company Name (to invoice)

Company Contact Name

Company Email 

Company Address (in full)

Deposit to pay

Do you have a Medical Card No?

Medical Card No.

Are you in receipt of a Dept. of Social Welfare Payment/Grant?

I would like to receive information on Lir Training Courses by email