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Client e-referral Form

JCP Centre name: JCP Adviser name:
Adviser contact number: Adviser email address:

Name of Client: Date of birth:
National Insurance Number:
Client Contact number: Client email address:
Client Address: Post Code:
Length of unemployment: Willingness to travel:

Benefit claimant:  If Yes state which:  
Mandated:     If Yes - Ref2:  


Training requirements (if known)
Is the customer willing to do a 2-day employability programme initially?


General comments (include support requirements, barriers, issues)

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