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THE INFORMATION ON THIS FORM WILL BE TREATED AS STRICTLY CONFIDENTIAL AND WILL BE USED
FOR MONITORING PURPOSES WHERE APPLICABLE. IT WILL NOT BE AVAILABLE TO MEMBERS OF THE
SELECTION PANEL. Please complete both sides of this form carefully and clearly. This form will be
separated from your application form prior to shortlisting. The information from this form will be processed
and used in accordance with the Data Protection Act for monitoring purposes and, if you are a successful
candidate, in connection with the management of, and relationship with you as an employee.
PERSONAL DETAILS
Title: Surname/Family Name: Forenames:
Daytime/Work No:
Evening/Home No:
Mobile No:
Email address:
Post Code:
NI No: DfES No:
Please state what personal facilities you are likely to need if appointed to the post:
Please state here what facilities or support you would require to assist you at interview:
Yes No
Do you have any current convictions or criminal charges pending?
If Yes, please give details:
To be completed by applicants for posts which are exempt from Section 4(b) of the Rehabilitation of
Offenders Act. Any failure to disclose such convictions could put your employment at risk.
Do you have any criminal convictions (including spent
Yes No
convictions)?
If Yes, please give details below or on a separate sheet
Are you a relative, partner or close friend of any member of the staff or Corporation?
DECLARATION
All or parts of the information on this form may be stored on computer files and used for the purpose of personnel
administration. Such use will be subject to the provisions of the Data Protection Act 1998. By signing the form it is
implied that you agree with these terms.
To the best of my knowledge the information given on this form and within the application form is correct. I
understand that canvassing or giving false information will disqualify my application, or lead to the termination of
any offer of employment. I also understand that should my application proceed to interview/offer of employment, I
will be required to produce supporting documentation as evidence of my qualifications, previous experience,
eligibility for employment and, where applicable, criminal convictions.
Email applications: If you are sending your application form by email, please tick the box below (as a substitute to
your signature) to confirm that you agree to the above declaration. Please note that when you submit this form by
email the information that is sent to us will not be encrypted. If invited for an interview, you will be asked to sign
this page.
Email substitution of signature
Signature Date
Candidate Number:
Post applied for and Reference Number:
(office use only)
Applicants should complete all sections of the application form in type or black ink. Do not leave sections blank or refer
the reader to your CV, although Curriculum Vitae may be enclosed to provide additional information.
Secondary
College/University
Professional Membership (if you are a member of any professional body(ies) please give details below)
Professional Body Level of Membership
3
WORK HISTORY
From: To:
Notice required:
Previous Work Experience (this may include periods spent at home with family or other commitments)
From To Employer's Name Position held and duties Reason for Leaving
2
ADDITIONAL INFORMATION IN SUPPORT OF YOUR APPLICATION
You are invited to provide further information in support of your application. Please make full use of this
section and continue on additional sheets if necessary. Make sure that you refer to the Person
Specification within the Job Description, and also include:
3
HEALTH (please note that all salaried appointments are subject to satisfactory medical clearance)
YES / NO
Are you suffering, or have suffered, from any major illness/industrial injury?
delete as applicable
How many days have you been absent from work due to sickness in the last 2 years?
EMPLOYMENT REFERENCES
Please give details of two people we may approach for references, one of whom should be your
present/last employer. Referees should be employment related, not personal referees.
Position: Position:
Company: Company:
Address: Address:
Email Email
address: address:
May we obtain a reference prior to interview? YES / NO May we obtain a reference prior to interview? YES / NO
delete as applicable delete as applicable
INTERVIEW AVAILABILITY (please indicate any imminent dates/times you are unavailable for interview)
If appointed, do you have any business or other interests which would conflict with the
YES / NO
duties of this post?
Do you hold a current driving licence? YES / NO
delete as applicable