Digital form

Enter WEX referral details directly

School *

Referral no.

Placement dates

Student name *

DOB *

Tutor group

Student email

Employer name and address *

Name of contact

Position

Tel

Mobile

Web

Main business

WEX job title/activities

Address confirmation

Days and hours

Dress code

Insurance company

Policy no.

Expiry date

Public liability cover5 or more employeesWritten risk assessmentsEmployer signed

Signatory position

Signatory print name

Signatory date

Parent/guardian name

Parent/guardian signed

Parent/guardian email