| 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) | Ms |
| All Forenames | MONIKA BARBARA |
| Surname | SHARMA |
| Surname at birth | OSIECKA |
| Date of birth | 02/06/1977 |
| National Insurance number | PX560245B |
| Home Tel | |
| Mobile Tel | 07999307777 |
| Other Telephone number | |
| Email Address | brokusltd@gmail.com |
| Place of Birth | Sochaczew |
| Nationality at Birth | Polish |
| What is your intended method of engaging with customers (you can tick more than one if applicable) | |
| Online | false |
| Telephone | |
| Face to face | True |
| If applicable, please include below details of any other forenames and surnames used | |
| Previous Name(s) | Osiecka |
| Date from | 02/06/1977 |
| Date to | 25/03/2000 |
| Reason(s) for change | marriage |
| Previous Name(s) | Baka - Osiecka |
| Date from | 25/03/2000 |
| Date to | 24/09/2003 |
| Reason(s) for change | re-marriage |
| Previous Name(s) | |
| Date from | |
| Date to | |
| Reason(s) for change | |