Royal Statistical Society
Centre for Statistical Education

First name

Family name

Name of University/College/Employer

Postal address of University/College/Employer

Phone

Fax

Your email address

Role at University/College (if appropriate)
Please state whether you are teaching, or are about to teach, statistics

Academic/Professional Qualifications
Please include name(s) of qualifications(s) and date(s) obtained

Teaching Experience
Please state the number of years of teaching experience, the subjects you have taught and the level at which you have taught these subjects

Name and address of a local person at your institution who will be your tutor/mentor and will be able to give you support, help and advice on teaching statistics

Name of tutor/mentor

Address of tutor/mentor

Mode of study
It is possible to use the material but not to be assessed for the Certificate. If you wish to use the material in this way, e.g. as part of an induction programme or for self study, please give details:

Fees:
Please give a billing address

Disabilities:
Please indicate if you have any disabilities relevant to your work for the Certificate

Please click "Submit" to send this form.

Please note, after filling out this form you will need to return by post a copy of a letter of support from a suitable mentor/tutor
(e.g. from your Department or the University/College Staff Development Unit) to:

Alison Davies
The Royal Statistical Society Centre for Statistical Education
Nottingham Trent University
Clifton Campus
Clifton Lane
Nottingham
NG11 8NS
U.K.