Goldsmiths - University of London

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Staff appointment request form

(1) Date

(2) Your name

Firstname

Surname

(3) Contact Information

Home address

Please ensure these are correct:

E-mail

Work phone

Home phone

Mobile

OK to email you? yes no
OK to contact you by mobile? yes no
OK to contact you on work phone? yes no
OK to contact you on home phone? yes no
OK to leave messages? yes no

(4) Date of Birth

(5) Department and Job title

(6) Availability
(please tick all times you can attend an appointment)

  9-10 10-11 11-12 1-2 3-4 4-5 5-6
Tuesday        
Thursday

(7) Anything else...
..you feel you need to tell us at this stage about this appointment request?

(8) Please note

As this form is no more "secure" than emails, if you are concerned about the possibility that this information may be seen by a third party over the internet, do not click the submit button - contact Mandi Weskin, Administrator to the Staff Counselling Service by phone (020 7919 7472) or in person instead at (20 Laurie Grove, Room 1).