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Welcome to CXC Global
Registration Form
Background Information
First Name:  * Surname:  *
Date of Birth [dd/mm/yy]: Who referred you to CXC?
Gender:  
Private Email:  *  
Repeat Private Email Address:  * Work Email :  *
Home Phone:  * Work Phone:
Mobile Phone:  * Fax:
UK Address: Street  
  Area  
  Town/City  
  PostalCode  
Nationality: National Insurance No:
 
Employment Information
Type of visa that allows you
to legally work in the UK:		 Employment Industry:
Contract start date:  dd/mm/yyyy Contract end date:  dd/mm/yyyy
Does your employment position involve
laying / installing / repairing cables?
(For Insurance Purposes)		 Yes No
Do you hold a CIS Card?
(This only applies to individuals working in the construction industry)		 Yes No
Employer / Agency Name: Employer / Agency Fax:
Contact Name: Contact Email:
Contact Phone:   Rate of Pay:  per 
 
Bank Account Information
Account Holder's Name: Account Number:
Sort Code: Bank Name:
Bank Address: Street  
  Area  
  Town/City  
  PostalCode  
Roll Number:
(If builidng society) 		 
 
Overseas Bank Account Information
Account Holder's Name: Account Number / IBAN:
Bank Name: BSB / SWIFT:
Bank Address: Street  
  Area  
  Town/City  
  PostalCode  
 
I confirm that I have not previously been the subject of a claim that would otherwise be covered by the Professional Indemnity Insurance Policy and that after reasonable enquiry I am not aware of any claims or circumstances that might give rise to a claim under the Professional Indemnity Policy.
 
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