| 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) | Mrs |
| All Forenames | Janine |
| Surname | Curtis |
| Surname at birth | Gascoigne |
| Date of birth | 26/05/1967 |
| National Insurance number | NM948421A |
| Home Tel | |
| Mobile Tel | 07971559905 |
| Other Telephone number | |
| Email Address | janinecurtis@hotmail.co.uk |
| Place of Birth | Sheffield |
| 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) | Gascoigne |
| Date from | 26/05/1967 |
| Date to | 26/05/1989 |
| Reason(s) for change | Marriage |
| Previous Name(s) | Curtis |
| Date from | 26/05/1989 |
| Date to | 08/05/2016 |
| Reason(s) for change | Marriage |
| Previous Name(s) | Southey |
| Date from | 08/05/2016 |
| Date to | 18/01/2022 |
| Reason(s) for change | Divorce |