Assessment Practising Certificate

1	Important Information Before applying for an APC through this form you must have joined The Dyslexia Guild (MDG/FDG level) and submitted your qualification information for approval and membership. You cannot proceed until this step has been completed.
2	Log In Please Login/Register first before filling in this form otherwise the system will not recognise your contribution. If you have lost your login details, use the Request New Password option on the login page and check your spam/junk email. If you have recently changed your email address, please contact APC Administrator via apc@dyslexiaaction.org.uk.
3	Payment Payment is by credit/debit card. If you require us to invoice your employer upfront you must first provide us with a Purchase Order by selecting the Pay Later* Option below on the form. If you select the Pay Later option your application process will not start until all fees are paid in full (including Guild Membership Fee). The Pay later options will also incur a £25 admin fee (£30 inc.VAT). If you pay online with a debit/credit card you will be sent a link from moodlesupport@dyslexiaaction.org.uk within 7-10 working days inviting you to upload your documents onto our Moodle site. please check your spam/junk folder*
?	Questions If you require any assistance completing this form please email us at apc@dyslexiaaction.org.uk or call us on 01784 222342. All boxes marked with a red * require a comment before you can complete the form.

Contribution Amount *

Renewal - £ 210.00 (includes VAT of £ 35.00)

Route 1 (Qualification under 5 years old) - £ 210.00 (includes VAT of £ 35.00)

Route 1 (Qualification over 5 years old) - £ 300.00 (includes VAT of £ 50.00)

Route 2 (APEL route, plus 7 years experience) - £ 585.00 (includes VAT of £ 97.50)

Total Amount

Account

Please enter a Username to create an account. If you already have an account please login before completing this form.

Username *

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Password

Confirm Password

Provide a password for the new account in both fields.

APC Personal Details + Payer Details

Title *

First Name *

Middle Name

Last Name *

Previous Surnames

Date of Birth *

Gender *

Female Male Prefer not to say

Street Address *

Additional Address 1

Additional Address 2

Town/City *

Post Code *

Country

Email Address *

Telephone No *

Mobile Tel. No

If some or all of your APC fee will be paid by a third party then please enter the contact details including Purchase Order Number, email, phone number and address (for invoicing purposes), and select Employer in the "Who will pay your contribution fee" box.

Who will pay your contribution fee?

Third Party Payer Details

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Last Name *

Street Address *

City *

Country *

County *

Postal Code *

1

Important Information

2

Log In

3

Payment

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Questions