Title of proposed course or learning activity:

Address

Telephone number

Cost of lessons

Date of lessons

I cerify that I wish my learning allowance to be used for the above learning activity, and that I would like Learning Works to raise a cheque payable to the Open University, or make payment to the Open University on my behalf for the above course, which I will undertake

• this application needs to be approved by Learning Works before the learning activity is undertaken
• an official receipt must be retained, and sent to Learning Works prior to 31st May 2012
• Your name
  

Staff number

Department