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Full Name: |
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Your address: |
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Postcode: |
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Daytime Telephone No: |
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Evening Telephone No: |
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Mobile Telephone No: |
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Email Address: |
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Date of Birth: |
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What is your occupation: |
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Education: |
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During the series, we shall be visiting London and various cities and towns around the country. Would you please name the venues most convenient for you: |
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What political party do you support: |
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Which of these groups do you consider yourself to belong to: |
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Do you consider yourself to have any disabilities: |
Yes No |
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If you are disabled, do you require wheelchair access: |
Yes No |
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Add any more relevant information. We need to contact each applicant, so if applying with friends or family, please give the names and daytime telephone numbers of each member of your group: |
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Suggest any questions or concerns that you will like to raise at the talk show: |
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What are the issues in society affecting you or someone you know today: |
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