Online Consultant vacancies application

Title (Mr/Mrs/Miss):

First name:

Surname:

Address:

Postcode:

Email:

Telephone:

Group:

Consultant's name:

Are you a member?

yes
past member

Current Weight Loss:

• please select stones kilograms pounds
• .0 .1 .2 .3 .4 .5 .6 .7 .8 .9 kg
• st 0 ½ lbs
• 0 ½ lbs
• *

Are you at your chosen target weight?

yes
no

How much weight would you like to lose, if not:

• please select stones kilograms pounds
• .0 .1 .2 .3 .4 .5 .6 .7 .8 .9 kg
• st 0 ½ lbs
• 0 ½ lbs

Occupation:

Occupation hours:

Full time
part-time
Not employed

Car driver:

yes
no

Own car:

yes
no

Own telephone:

yes
no

Do you have 10-15 flexible hours free per week?

yes
no