LAYC On-Line Disclosure Application

Please complete this form using BLOCK CAPITAL letters. The information you provide is manually entered on to a Disclosure Application which you will be required to check and sign at the identification verification stage of the process. If you have any queries relating to the information requested below please do not hesitate to contact us at LAYC on 0131 667 1828 or email enquiries@layc.org.uk

Details of Club / Group
Club/Group/Organisation name:
Position applied for:
Name(s)
Title: Mr Mrs Ms Miss Dr Other
If other please state:
Present surname:
Present forenames (please include all middle names):
Mothers Family/Maiden Name:
Name at Birth (Only complete if different to present name e.g. if you have changed your name because you are married)
Surname:
Forenames (please include all middle names):
If you are known by, or have previously been known by, any other name then enter the details here
Surname:
Forenames (please include all middle names):
Birth Details
Date of Birth dd/mm/yyyy: / /
Gender: male female
Town of Birth:
Contact Information
Telephone Number (incl. STD code):
Email address:
Current Home Address
Address (number, street)
Post Town
County/Region
Country (leave blank if UK)
Post Code
Resident from dd/mm/yy: / / /
Home Address History
If you have not lived at your current home address for five years, then please provide your previous addresses covering this period with the most recent first etc.
Address (number, street)
Post Town
County/Region
Country (leave blank if UK)
Post Code
Resident from yyyy:
Address (number, street)
Post Town
County/Region
Country (leave blank if UK)
Post Code
Resident from yyyy:
Address (number, street)
Post Town
County/Region
Country (leave blank if UK)
Post Code
Resident from yyyy:
Address (number, street)
Post Town
County/Region
Country (leave blank if UK)
Post Code
Resident from yyyy:
Address (number, street)
Post Town
County/Region
Country (leave blank if UK)
Post Code
Resident from yyyy:
Address (number, street)
Post Town
County/Region
Country (leave blank if UK)
Post Code
Resident from yyyy:
Address (number, street)
Post Town
County/Region
Country (leave blank if UK)
Post Code
Resident from yyyy: