Applicationfor

Employment

Allpersonal datasuppliedtousonthisformwhichissubsequently processedoncomputerorbyothermeans, issubject totheprovisionsoftheDataProtectionAct1998. Please complete the form IN FULL either by typescript or using black ink. Please ensure that any gaps in employment or educational history are covered.

Positionappliedfor:

Personal Details(CAPITALLETTERS PLEASE)
Surname: / Title:(e.g.Mr/Mrs/Miss/Ms/Mx/Dr)
Forename(s):
Address:
Postcode:
Telephone:(homeand/ormobile) / Telephone:(work if it may be used)
EmailAddress: / NationalInsuranceNumber:
Doyouneed aworkpermittoworkintheUK?YES/NO
IfNo,please provideacopyofyourworkpermit / Areyoufreetoresideand/or workintheUK?YES/NO
Doyourequire assistance inordertoattendaninterview?
HaveyoupreviouslyappliedtotheOuthouse Eastforaposition? YES/NO
Pleasegivedetailsifapplicable
Where did you first see this role advertised?
Present orMostRecent Post,includingself-employment
NameofEmployer:
Employer'sAddress:
PostCode:TelephoneNo.:
CurrentPosition/JobTitle:
Salary: / Hours:
Employmentstatus: (e.g.permanent short-term, full-time,part-time, self-employed)
Datecommenced: / Finishdate:(ifapplicable)
Noticeperiod: / Ifappointed, whenwouldyoubeabletostart work?
Brief summaryofduties
Reasonforleaving

Previous Employment

Pleaselistdetailsofallpostsyouhaveheld,startingwiththemostrecentbutexcludingyourcurrentpost

From
(month/year) / To
(month/year) / Employer'sname,address typeofbusiness / Postheld(fulltimeorparttime) / Reasonforleaving
Education (inchronologicalorder) / Original documentary evidence of qualifications will be required of applicantsshortlisted for interview
From
(month/year) / To
(month/year) / School/college/university / Qualificationsobtained
Includesubjects,datesgrades
Professional Qualifications/Other Training/ FurtherStudy
Qualification/CourseTitle
(include briefdescription) / Organising Body / Date

Person Specification

Pleasedescribe belowhow you meet the essential and/or desirable knowledge, skills and experience outlined in the person specification. Thismightincludeskillsdevelopedinpaidemployment/voluntarycommunitywork/leisure interests.Continueon aseparate sheetif necessary.

LGBT experience

IPlease detail any knowledge or experience of working with the LGBT community.

Any other information

IPlease detail any other information you feel is relevant to this position.

General L

This post is exempt from the provisions of the rehabilitation of Offenders Act 1974. Shortlisted candidates will therefore be required to disclose all criminal convictions or cautions including any which may be “spent”.

Employment for the successful candidate will be on condition of receiving a satisfactory Enhanced Disclosure and Barring Service certificate as the post will involve interaction with children and young people.

1.Haveyoueverbeenconvictedofacriminal offence?YES/NO

Ifyes,please specifydateofconviction,court,natureofoffenceandsentenceimposed

References

Pleasegivethenamesandaddressesoftworeferees, one of which must be yourpresent/most recentemployeroreducationalestablishment. Referees maybecontacted priorto short-listing unless you indicate otherwise.Ifeitherrefereeknewyoubyanothername, pleasegivedetails.

Name: / Name:
Address: / Address:
Postcode: / Postcode:
Tel: / Tel:
Fax: / Fax:
E-mail: / E-mail:
May we contact prior to short-listing or interview? / May we contact prior to short-listing or interview?

Declaration

Icertifythat tothebest ofmybelief,theinformation IhaveprovidedistrueandaccurateandIunderstand thatanyfalseinformationorfailuretodisclosecriminalconvictionsmay intheeventofemployment,resultindismissal ordisciplinaryaction.

SignedDate

Please returnthecompleted formto:

Changing Attitudes, Changing Lives

19 East Hill

Colchester

CO1 2QX

e-mail:

Tel:01206871394

EqualOpportunitiesinEmployment

Outhouse Easthas anEqualOpportunitiespolicy inplace. Toassist intheimplementationandmonitoringof ourEqual

Opportunities policy please provide the following information.

Name
Job applied for
Gender Identity
Female / Male
Transgender Female / Transgender Male
Non-Binary / Prefer not to say
Other (please specify)
Ethnic Origin
Iwoulddescribe myself as(pleaseticktheappropriate)box):
White British/English
White Irish
White–other(pleasespecify)
Black–British
Black–Caribbean
Black–African
Black–other(pleasespecify)
Indian
Pakistani
Bangladeshi
OtherAsian(pleasespecify)
Chinese
Mixedparentage(pleasespecify)
Age
16-19 / 20-29 / 30-39
40-49 / 50-59 / 60+
Disability
Doyouconsider yourselftohaveadisability?
Yes / No
Ifyes,pleasespecify

Theinformationyouprovidewillbetreatedinthestrictest confidence andwillnotbeavailable, exceptin statisticalformat,totheshortlistingpanel.

Ifyouhaveanyquestions regardingthisform,please email .

Thank youfortakingthetimetocompletethisform.