The Disciplinary Officer of the Relevant Disciplinary Body will use the information contained in this form, along with other conduct history and information it holds about the Participant, to determine what disciplinary action (if any) is to be taken. The Disciplinary Officer may pass it on to a Disciplinary Chair or Disciplinary Panel where necessary who may use it to assist in their disciplinary decisions.

** This form will be automatically submitted to the Disciplinary Manager. You will also receive an copy for your own records to the email address that you specify below, so please ensure that it is correct **