Please complete this form as thoroughly as possible and return it by email or post along with a current version of your C.V. to:

Email:

Post: H.R. Department, The Grange, Rectory Lane, Bookham, Surrey KT23 4DZ

Post applied for / Service
Where did you see the vacancy advertised?
Surname / Title / Mr / Mrs / Miss / Ms / Other
First Name (s)
Previous Names (if any)
Address
Post Code
Telephone Number / Email
Qualifications
Please list any qualifications you have gained in chronological order from GCSE or equivalent.
If you are offered the role you will be required to produce documentary proof.
Secondary schools/college/
University/training institute / Dates
From/to / Examinations
(state subjects/grades/
Qualification/other training (e.g. NVQ) / Grade
If
Applicable / Date
Gained
Are you a member of a professional body? If yes please give details:

Work History

Please give details of your full work history beginning with your present or most recent position and then work chronologically backwards explaining any gaps in employment (use separate sheet if required). Alternatively, please submit a full and up to date CV.
Date
From / Date
To / Name and address of employer / Job title and description of duties and responsibilities / Reason for Leaving / Salary on leaving
Current Notice Period
Personal Statement
Please provide a brief statement as to the reasons you are interested in the role and why you believe you are a suitable candidate. Please be specific and give examples wherever possible; these can be drawn from any aspect of your life.
Administrative Details
National Insurance Number
Do you have the right to work in the U.K.?
N.B. if called for interview you will need to provide evidence. / Yes / No
If you have a working visa, when does it expire?
Is anyone in your household or family an employee at the Grange? / Yes / No
If yes, please provide details:
Do you hold a current full driving licence? / Yes / No / Any endorsements? / Yes / No
Have you ever been convicted of a criminal offence?
Please note, all post at the Grange are exempt from the Rehabilitation of Offenders Act 1974 (Exemption Order 1975). All previous arrests or convictions must be disclosed. Appointment is subject to check Disclosure and Barring Service (DBS) and Protection of Vulnerable Adults Register. / Yes / No If yes, please provide details:
Referees
Please give details of two referees. If you are (or have recently been) employed, one must be your current or last employer. If you are a student, one should be a senior staff member from your place of study.
If you have only one employer / academic referee the other should be someone who has known you for at least 3 years but is not related to you (e.g. GP, solicitor).
Referee Name & Positiona / Telephone Number: / Employer / Academic / Personal*
* Delete as appropriate
Email:
Address: / May we contact this referee without any further authority from you?
Yes / No
Referee Name / Telephone Number: / Employer / Academic / Personal*
* Delete as appropriate
Email:
Address: / May we contact this referee without any further authority from you?
Yes / No
If you have previously worked with children or vulnerable adults, you must provide the following:
Employer Name / Contact Name & Telephone Number / May we contact this person without any further authority from you?
Declaration
I confirm that the information given on this form and any attachments is correct and complete, and that misleading statements may be sufficient for cancelling any agreements made. I understand that because of the sensitive nature of the employment, an enhanced disclosure will be sought from the Disclosure & Barring Service in the event of a successful application and that documentation will be required for identification. I also understand that the information provided will be processed and I hereby give consent for data processing under the Data Protection Act 1998.
Signed / Date

Please ensure you have enclosed a current C.V. with your application if you have not completed the work history section.

The Grange Centre for people with disabilities founded in 1927, is a registered charity No. 207740, a company limited by guarantee and registered in England (Companies Act) No. 348341, registered Housing Association No. H3727

www.grangecentre.org.uk

EQUAL OPPORTUNITIES MONITORING FORM

The Grange is an Equal Opportunities employer and we do not discriminate on the grounds of age, disability, marital status, race, religion, caste, sex or sexual orientation. In order to help us monitor the effectiveness of our Equal Opportunities policy you are asked to provide the information requested below.

This information is confidential and does not form part of your application. This slip will be detached from your application form when it is received and the information will not be taken into account when making the appointment.

Date of Birth
1 / Are you: / Male / 7 / To which of these groups do you consider you
Female / belong? (tick one only)
2 / Do you consider / Yes / (a) / White
yourself to have a disability? / No / British
(Please see / Irish
information for / Any other white background
disabled candidates / (please write in): …………………
overleaf) / (b) / Mixed
White and Black Caribbean
3 / Are you currently / Yes / White and Black African
employed by The Grange Centre / No / White and Asian
Any other mixed background
4 / Marital Status / Married / (please write in): …………………..
Single / (c) / Asian or Asian British
Separated / Indian
Divorced / Pakistani
Widowed / Bangledeshi
5 / Religion / None / Any other Asian background
Christian / (please write in): …………………..
Buddhist / (d) / Black or Black British
Hindu / African
Muslim / Caribbean
Sikh / Any other Black background
Jewish / (please write in): …………………
Other / (e) / Chinese or other ethnic group
………….. / Chinese
6 / Sexual Orientation / Any other ethnic background
Optional / …………. / (please write in): …………………..

Information for Candidates with a Disability

The Grange welcomes applications from all sectors of the community, including candidates with a disability.

Disability is defined by the Equality Act 2010 as:

‘...a physical or mental impairment that has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities...’

1. Arrangements if selected for interview

If you have a disability, please indicate whether you would need any of the following arrangements to be made if you were invited to interview:

Interview information on audio tape / Induction loop in interview room
Interview information in large print format / Wheelchair-accessible location for
interview
Sign language or other assistance with
communication at interview (please specify / Car parking space for interview
the exact type of service required:
Facility for personal carer, assistant
or other person to accompany you at
interview
Other requirement(s) - please give details

2. Arrangements if appointed

Please give below details of any adjustments which would need to be made in order for you to be able to carry out the duties of the job if appointed.