Barry Bennett Technical Assessment Form

Please complete the form below to request a technical assessment.
Fields marked with an asterisk (*) are required.

Referrer details



Assessment centre:*

Referrer / assessor name:*

Referrer / assessor telephone no:*

Referrer / assessor e-mail:*

Assessee details


Name:*

Address or location to be assessed at:*

Assessee telephone no:

Assessee e-mail:

Sex:*
 Male  Female

Type of assessment required:*




Relevant background information relating to disability / current issues:

Any assistive technology currently being used - please include specification if appropriate:

Assistive technology you would like us to demonstrate on-site - please state range of products / specific items:

Duration of studies remaining, including any part years:

*For security purposes, please type the letters in the image.