18 June 2012 Last updated at 05:44 ET

Audience plea for Scottish referendum debate programme

The future of Scotland has been the focus of an ongoing debate

BBC Scotland is appealing for members of the public to join an audience for the latest in a series of debates on the future of Scotland.

The television special will take place on Friday, 29 June.

Both the Scottish and UK governments have held consultations into the issues surrounding a referendum on Scottish independence.

SNP leader and First Minister Alex Salmond has named autumn 2014 as his preferred date to hold the vote.

The venue for the debate, featuring a panel of politicians and being hosted by political editor Brian Taylor, will be BBC Scotland's Glasgow headquarters at Pacific Quay.

The programme will be broadcast at 19:00 on Friday on BBC One Scotland.

When, where, time?

• Friday, 29 June
• BBC's Pacific Quay, Glasgow
• Time - from 13:00 onwards

If you are interested in joining the audience, fill in the form below.

People wishing to take part will need to be available from 13:00 and for the rest of Friday afternoon.

Guidelines require the BBC to have a balanced audience for this event.

To help us do this, we will ask all members of the audience whether they are associated with a political party or if they already have a favoured view on whether Scotland should become independent or remain part of the UK.

1. Name and address

Full name*

Your Address

Your postcode

2. Your Contact Details

Daytime*

Evening*

Mobile

Email address*

3. What is your occupation?

4. What is your preferred option for Scotland's constitutional future?

Devolution under current arrangements? Devolution with significantly increased powers? Independence?

Other

5. If there were a General Election tomorrow, which political party would you be most likely to vote for?

Conservative Labour Liberal Democrats Green Scottish National UKIP Would not vote Undecided

Other (please state)

6. Are you a member of a political party?

Yes No

If Yes which party

7. The audience for BBC Scotland TV Debates is totally proactive and we wish to ensure that the opportunity to put forward questions and take part in the debates is given to those people wishing to participate. Would you please confirm that you are keen to get involved and if selected will ask your question.

Yes No

8. What two questions would you like to ask?

9. Which of these groups do you consider yourself to belong to?

White African-Caribbean Indian Pakistani Chinese African Mixed origin

Other (please specify)

10. Do you consider yourself to have any disabilities?

Yes No

11. If you are disabled, do you require wheelchair access?

Yes No

12. Have you been on a BBC Scotland TV or Radio Debate before?

Yes No

13. How old are you?

16 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+

14. The information you provide will be collected by the BBC. Are you happy for your email details to be retained so that we may contact you about appearing in the audience for other BBC programmes?

Yes No

* Required information