19+ Agreed Change Submission19+ Non-Apprenticeship Agreed Change submissionWhere there are any agreed changes to be made to the Learning Agreement, such as changes to qualification aims these should be formally submitted via this form.All changes (excluding learner personal details) must be signed and agreed by all parties (Learner and Training Provider). Where a Supporting Provider is involved in the delivery they can sign on behalf of the training provider.A form must be completed and signed for every change made. Learner First Name:Learner Date of Birth:Learner Surname:Course:Please select the change type agreed: Learner Name Learner Address Learner Contact Number Learner Next of Kin Details Change of Start Date Change of Qualification Change of Tutor/AssessorPrevious Name:Updated Name:Name Change EvidenceChoose File Previous AddressNew AddressPrevious Telephone NumberNew Telephone NumberNew Next of Kin Name:New Next of Kin Address:New Next of Kin Telephone Number:Please provide QAN code of qualification that requires changingPlease provide QAN code of new qualification:Please provide reason for change:Will the new qualification require different start and planned end dates? Yes NoPlease provide start date of new qualification:Please provide planned date of new qualification:Please provide new Start Date:Will the planned end date also require amending Yes NoPlease provide new Planned End Date:Name of new Tutor / Assessor:Date in which the change will take effect:Please state the reason for the change in start date (Please note that it may not be possible to amend dates within the previous academic year) :DeclarationBy signing this form I agree to the above changes being made. Please note that where there is an amendment to start date the MIS Department may require additional evidence from the learner in order to claim ESFA funding. Where a learners details such as their employment status changes prior to their new start date they must inform the MIS Department of these changes by e-mailing: wbl@achievementtraining.comLearner Signature: Sign HereTutor/Assessor Name:Tutor/Assessor Signature: Sign HereSubmit Form