Learner Registration Form

First Name
Surname
Address 1
Address 2
Town
County
Email Address
Landline No.
Date of Birth
Course Code & Title
Choose Course
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
Lir Business Services & Training Centre Ltd
Mullingar,
Co. Westmeath,
Ireland.
Ph: 044-9342754
training@lirbusinesscentre.com

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