Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 1

All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Application Form

To be completed in typed form or in your own handwriting in black ink Bold bordered sections are mandatory fields

Refer carefully to the job description and person specification. If the space provided is insufficient please continue on a separate sheet. Post Applied for:

Vacancy

Reference No:

Where did you first find this vacancy?

(If in publication, please state which

one. If from current employee of

Creative Support, please state name)

Company Website Jobcentre Guardian Charity Jobs

Reed Other (State) Preferred Client Group and Hours:

Mental Health Learning Disabilities Other

Older People No Preference Office

Full Time

Part Time

Have you a current in-date DBS

Certificate?

Yes No

Is it registered for the DBS

update service? (£13 per year

subscription)

Yes No

Have you previously applied for a post

with Creative Support?

Are you over 18 Years Old

Yes No (If Yes, please specify):

Yes No

Personal Details Title:

Forename(s) or other names

Surname

Address

Postcode:

Telephone

Home: Work:

Mobile:

Email Address

Car Driver: Yes No Car Owner: Yes No

Do you have any endorsements on your licence?

(if so please outline why)

Yes No

Are you a UK or EU/EEA national?

(If so you will need to provide proof of this at your interview)

Yes No

If you are not a UK or EU/EEA national can you provide proof of permission to work in the UK?

If you cannot provide proof of permission to work in the UK we cannot accept your application as you are unable to work legally in the UK.

If you can provide proof of permission to work please state the nature of your permission to work in the UK, any restrictions on the hours you are permitted to work and the expiry date of the permission.

Yes No

We will require sight of the documentation which

confirms that you are permitted to work in the UK at the interview stage. We may need to take a copy of the document and to carry out checks to authenticate it. Describe the type of permission to work in the UK: Hours permitted to work:

Expiry Date:

Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 2 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Employment History

Present or most recent employment (paid or unpaid) This includes any roles prior to moving to the UK (if applicable) Employer Name, Address

including Post Code and

Telephone Number

Date(s)

Employed

Position(s) Held and

Salary

Employed/Self Employed

Employed

Self Employed

Outline of Duties and Responsibilities:

Reason For Leaving

Please state reason for leaving and confirm current employment status: Number of Weeks Notice Required:

Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 3 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Previous Employment

Please list in chronological order with your most recent post listed first including temporary, casual and short term jobs

(Please give your full employment history since leaving school. If you require extra space please attach an additional sheet)

Employer Name, Address including

Post Code and Telephone Number

Date(s)

employed

Position(s) held and

salary

Reason for leaving

Outline of Duties and Responsibilities

Employer Name, Address including

Post Code and Telephone Number

Date(s)

employed

Position(s) held and

salary

Reason for leaving

Outline of Duties and Responsibilities

Employer Name, Address including

Post Code and Telephone Number

Date(s)

employed

Position(s) held and

salary

Reason for leaving

Outline of Duties and Responsibilities

Employer Name, Address including

Post Code and Telephone Number

Date(s)

employed

Position(s) held and

salary

Reason for leaving

Outline of Duties and Responsibilities

Gaps in Employment

Please give details of all periods when not in employment, giving dates and reasons

Dates from: To: Reason:

Dates from: To: Reason:

Dates from: To: Reason:

Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 4 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Have you ever been dismissed from a previous post or had an employment contract terminated for any reason including redundancy? If so please give details below: Have you been subject to disciplinary action in your current or any previous posts? (including being the subject of any disciplinary process not yet concluded to resignation) If yes, please give details: Voluntary Work Experience

Give details of any voluntary or unpaid experience including care of others Language Skills

List all languages spoken fluently and those in which you have a good working knowledge Please tell us why you are applying for

this post and why you want to work for

Creative Support

If in current employment, please explain why you are looking for a new post:

Do you have any restrictions in your

working hours or availability?

Please note our requirements in respect

of working hours as detailed within the

Job Description

Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 5 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 General Education Qualifications Achieved

School/College From To

Subject/courses studied, level and grade

(eg, GCSE, ‘A’ Level, GNVQ etc)

Further and Higher Education Qualifications Achieved College/University From To

Subject/courses studied, level and grade (eg, BA History 2:1)

Professional Training Qualifications Achieved

College/University

From

To

Subject/courses studied, level and grade (e.g., BA Social Work/DipSW 2:1)

Professional Membership of Registered Bodies Registration No/Renewal Date Name of Professional Body and

Level of Membership

Date

Nurses, please give PIN No.

Social Workers please give GSCC Registration No

NVQs and other work related qualifications Qualifications Achieved College/Training Provider From To

Awarding body, level and grade if applicable (eg,

Edexcel NVQ 4 Pass)

Other vocational and work related training undertaken List subjects, e.g., First Aid Duration (e.g., 1 day) Level (if appropriate) Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 6 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 Additional Supporting Information

What experience have you gained in your current and previous jobs and general life experience, which you feel would be relevant to the job you are applying for?

The job description and person specification outline the values, skills, abilities, knowledge and personal qualities required for this post and the organisation. Continue on a separate sheet if necessary. If you wish to attach a CV or other information please do so.

Authorised by: Anna Lunts Date First Authorised: June 2009 Page Number: 7 All employees are subject to enhanced DBS checks Version 6.8 – November 2017 References

Please supply the names and addresses of two professional referees who have agreed to provide a reference. It is essential that one of your referees must be your current or most recent employer* and that your referee is/was your line manager and not a colleague, relative or friend. Both references cannot be from the same company. References will be verified to ensure authenticity. Failure to provide the above can result in your application being withdrawn.

*If previously self-employed, please provide two professional referees and detailed information regarding your self-employment

Current employer or

most recent employer

details

Company

(Business Addresses

Only)

Name

Position

Address

Post Code:

Tel

Fax

Email

Can this reference be contacted prior to interview Yes / No Previous employer (if

not applicable an

academic referee)

Company

(Business Addresses

Only)

Name

Position

Address

Post Code:

Tel

Fax

Email

Can this reference be contacted prior to interview Yes / No

* Unless indicated otherwise all referees will be contacted following your notification of success at individual Interview

DATA PROTECTION ACT

In accordance with the Act, you should be aware that the personal details submitted with this application form will be used only for selection and interview procedures; and for employment records if the application is successful. DECLARATION

I declare that, to the best of my knowledge and belief, all statements contained in this form are correct and I understand that should I conceal any material fact, I will, if engaged, be liable to the termination of my contract of service with such notice as may be appropriate.

Signature: Date: Have you ever been convicted of any criminal offence? YES NO Please note that all positions are subject to an enhanced DBS check. You will be asked to declare all criminal convictions in further details if an offer of employment is made.

Contact this candidate