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Application Form

We are committed to equal opportunities and welcome applications from all sections of the community.

PLEASE COMPLETE THE APPLICATION FORM IN FULL

Post Applied For *

Job Reference No

Closing Date

1. PERSONAL DETAILS

Title *

Name *

Address *

Postcode *

Email address *

Telephone Number (Home)

Telephone Number (Work)

Telephone Number (Mobile) *

Can we contact you at work? *YesNo

Do you have an entitlement to work in the United Kingdom? *YesNo

If yes, is your entitlement time limited? YesNo

Entitlement Expiry Date:

National Insurance Number: *

Do you have a driving licence? *YesNo

If yes, please indicate type:

Do you have any live endorsements/penalty points? *YesNo

If yes, please provide details:

Do you have business insurance? *YesNo

2. PRESENT/MOST RECENT EMPLOYMENT

Job title *

Employer name *

Employer address *

Current salary/hourly rate

Notice required *

Employment start date

Employment end date

Brief Outline Of Job Role & Responsibilities

3. Previous Employment

Starting with most recent, please ensure you include all employment since leaving school or full time education and explain all gaps in your employment history.

Employer’s Name	Position Held/Reason for leaving	From date	To date

4. EDUCATION/QUALIFICATIONS

Give details of all secondary schools/colleges attended. You will be required to provide evidence of qualifications gained.

Name of Secondary School/College/University	From date	To date	Qualification	Grade attained

Membership of Professional Associations

Please give details of the name of the association, membership grade/level and membership number

5. RELEVANT TRAINING AND NON QUALIFICATION COURSE

Provide details of any training that may be relevant to your application including dates/duration.

Training Course	Date

6. SUPPORTING INFORMATION

Use this section of the application form to explain why you are applying for the job, concentrating on how your skills, knowledge and personal qualities match the requirements of the person specification.*

7. REFERENCES

Please enter the names and addresses of two referees. One should be your present or most recent employer. References will only be taken up and considered after selection and an offer of employment has been made.
(Please note that relatives or friends may not be used as a referee). With the exception of your current employer YOU MUST SEEK THEIR PERMISSION BEFORE SUBMITTING THEIR NAMES.

1. Referee

Name *

Company Name *

Relationship *

Address

Postcode

Telephone Number *

Email address *

2. Referee

Name *

Company Name *

Relationship *

Address

Postcode

Telephone Number *

Email address *

8. RELATIONSHIPS

Are you related to any Employee or Client of Select Support Partnerships? *YesNo

If yes, please provide Name:

Relationship:

9. CRIMINAL RECORD BUREAU/INDEPENDENT SAFEGUARDING AUTHORITY CHECKS

Offers of employment to regulated/controlled and exempt posts will be subject to a satisfactory enhanced disclosure via the Disclosure and Barring Service.

The Safeguarding Vulnerable Groups Act

In 2012 the new Disclosure and Barring Service (DBS) was launched. All applicants for posts that are defined as a ‘regulated’ or ‘controlled’ activity within the Company will be subject to an Enhanced Disclosure via the Disclosure and Barring Service.

Rehabilitation of Offenders Act

The Rehabilitation of Offenders Act allows for a person who has been convicted of a criminal offence involving a sentence of not more than 2 years imprisonment and who has since lived trouble free for a specified period of time (related to the severity of the offence) to be treated as if the offence, conviction or sentence had never occurred. This is known as a spent conviction.

The job for which you are applying is one of those to which the provisions of the above Act in relation to spent convictions, do not apply. You must, therefore, disclose whether you have any previous convictions, whether or not they are spent.

Should you identify that you have a criminal conviction, this will be discussed in confidence at interview. However you should you not disclose any conviction you have it could lead to your application being rejected, or, if you are appointed, may later lead to your dismissal.

People who have convictions will be treated fairly and given every opportunity to establish their suitability for the job. Any information that you give will be kept in strict confidence and will be used only in respect of your application for this job.

Only convictions that are relevant to the job in question will be taken into account.

Do you have any spent criminal convictions? *YesNo

If yes, please give details:

10. DECLARATION

To the best of knowledge and belief all the particulars I have given are true. I acknowledge that providing incorrect information or deliberately concealing any relevant facts may result in disqualification from the selection process or where the discovery is made after an appointment in termination of contract. I also understand that no offer of employment made to me will be binding unless confirmed in writing. *

Date *

Select Support is committed to protecting your privacy by making sure that your personal information is held securely. We limit access to the personal information contained within your application to certain organisations who have statutory or regulatory responsibilities and to trusted, non-commercial organisations to enable research about recruitment in the Health and Social Care Sector.

When you submit this declaration, you will be providing your consent to the use of your personal information, as defined by the Data Protection Act 1998, by Select Support Partnerships Ltd. *

Date *

11. Equal Opportunities

How would you describe your ethnic origin?
This question is not about nationality or citizenship: It is about colour and broad ethnic group.
UK Citizens can belong to any of the groups listed. Please select appropriate answer.

Your ethnicity *WhiteBlack – CaribbeanBlack – AfricanBlack – OtherIndianPakistaniBangladeshiChineseOther

What is your nationality?

Are you: *MaleFemale

Are you: *MarriedSingleOther

Please select your age group: *18-2526-3536-4546-5555+

Are you registered disabled? *YesNo

The Equal Opportunities information is to develop our equal opportunities policy and is used only for monitoring purposes.

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