| The details which you provide within this application form are the basis of your disclosure. Credit Checks & Criminal Records Bureau Checks will be made and references taken, therefore the omission of any relevant details may result in your application being delayed. | |
| Title (If other, please state) | Mr |
| All Forenames | Samuel |
| Surname | Wheeler |
| Surname at birth | Collins |
| Date of birth | 30/08/1995 |
| National Insurance number | PA463898C |
| Home Tel | |
| Mobile Tel | 07800534667 |
| Other Telephone number | |
| Email Address | swheeler-95@outlook.com |
| Place of Birth | Chatham |
| Nationality at Birth | British |
| What is your intended method of engaging with customers (you can tick more than one if applicable) | |
| Online | True |
| Telephone | True |
| Face to face | True |
| If applicable, please include below details of any other forenames and surnames used | |
| Previous Name(s) | Collins |
| Date from | 30/08/1995 |
| Date to | 06/01/2017 |
| Reason(s) for change | I grew up never knowing my real dad. My grandad died in December 2016 therefore I changed my surname to his surname in memory of him. |
| Previous Name(s) | |
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| Reason(s) for change | |
| Previous Name(s) | |
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| Reason(s) for change | |