Withdrawn: This publication has been withdrawn. It is no longer current.

European Social Fund

  Unique identification number if applicable.			
             
To: Jobcentre Plus contact name and address			From: Prime Provider’s contact name and address	

			

CPA & Prime contract  no:			        	Phone number		

Section 1: Individual’s Details
Method of referral 	LA referral		             Secondary Referral Route			

Has an ESF 14 previously been submitted for this person?	Yes                                   No	

National Insurance Number               														
Title		

Forename / Other names		

Surname		

Address		
		
	                                                                 Postcode	

Gender	Male		Female			Date of birth	                 /                 /	

Ethnicity (tick one)		Black or British Caribbean		Mixed: White and Black Caribbean		Asian or Asian British: Indian		Chinese		
										
White: British		Black or British African		Mixed: White and Black African		Asian or Asian British: Pakistani		Other Ethnic Group		
										
White: Irish 		Black or British Other 		Mixed: White and Asian		Asian or Asian British: Bangladeshi				
										
White: Other 		Mixed: Other		Asian or Asian British: Other		Prefer not to say				

Substantial/long term impairment               				Yes		No		If Yes, please state		

Benefit	

Section 2: More information for the Individual	
Storing of your personal information
By signing this form, you:

•	allow Jobcentre Plus to store your basic personal information, included on this form, to make a referral to the Provider 
•	or to ‘qualify’ members of your family for ESF provision, where you have agreed to this.

We may use the information you give us to
•	research how well European Social Fund programmes work*
•	link with other information we hold about you, if you are in receipt of a DWP working age benefit 

* We may contact you to ask you some questions.

How we collect and use information
The information we collect about you and how we use it depends mainly on the reason for your business with us.  We may use it for any of the Department’s purposes which include
- social security benefits and allowances child support                                     - private pensions policy
- employment and training                                                                                 - retirement planning.

We may get information from others to check the information you give to us and to improve our services.  We may give information to other organisations as the law allows, for example to safeguard against crime.

To find out more about how we use information, read our Personal information charter or contact any of our offices.	

Section 3: Individual’s Declaration to be completed after the participant has read Section 2

The information I have provided is current and correct to the best of my knowledge and will be used by the provider named on this form to register me and/or my family:

Do you want to participate?                                                                              	Yes / No	
I agree that my information can be used to qualify myself and other members of my family to join this ESF provision.	Yes / No	

•	I understand that the information may be used for other purposes relating to the work of the Department for Work and Pensions.
•	Some information may be given to other government bodies as permitted by law
•	I have been informed and understand that the activity delivered by the provider named on this form is funded by ESF, and I 	have received leaflet DWPF06.
•	Where I receive benefit I must promptly tell the office that pays my benefit of anything that may affect my entitlement to, or the 	amount of that benefit.
 Individual’s signature		
	
              Date	                      /               /	

Section 4: Provider Declaration – to be completed by the DWP ESF provider and not by the participant

Qualifying Person’s name		
Qualifying Person’s National Insurance Number		

Identity documents seen for the person named in Section 1	Yes		

Completed by (print name &
Organisation)			
Signature 	
		Date 	               /               /	

   Section 5a: Jobcentre Plus use
PRaP referral made \ form returned if a qualifying person only	
 
Form Processed by (Name)
			           Date	               /               /	
Form Processed by (Signature)

Section 5b: Jobcentre Plus use
 Unable to make PRaP referral ( please explain why in ‘reason for return’ box below)					
Form Returned to Provider	Date   
                  /               /		
Reason for return		
Accept the amendments               
		Date of acceptance	                /             /