Application Form for the Post Of

APPLICATION FORM FOR THE POST OF

Independent Living Support Assistant

This application needs to be fully completed and emailed to or alternatively you can print the form out and return the completed copy to Employee Services Helpdesk, Room 323, Guildhall, Swansea, SA1 4PE

Please note:

City & County of Swansea is acting on behalf of a third party and will not be your employer or be liable for any issues arising out of your employment should you be offered employment.

Your personal information will be held and used in accordance with the Data Protection Act 1998. The information you have provided will be forwarded to the third party for whom we are acting and will be used to contact you in association with this job application only. It will not be used for any other purpose or shared with anyone else outside of the organisation.

PERSONAL DETAILS:

Full Name:

Address:

Postcode:

Email address:

Telephone number: Daytime: Evening:

N.I. number (or work permit no):

If you do not have a N.I number please give a brief explanation why:

The Direct Payments Team within the City and County of Swansea will create a ‘Pool’ of Independent Living Support Assistants. The team will then contact applicants when potential vacancies arise.

Do you agree for your application to be held within this pool? Yes/No* (*delete as applicable)

Do you have a full UK Driving Licence? Yes/No* (delete as applicable)

Do you have access to a vehicle you could use for work purposes? Yes/No* (delete as applicable)

What is your preferred location for work? ______

What is your preferred client group? Adult/Children/No preference* (delete as applicable)

Please confirm the Days/Hours you are available for work (please circle):

Monday / AM (6am-12pm) / PM (12pm – 6pm) / Evening (6pm – 11pm) / Anytime
Tuesday / AM (6am-12pm) / PM (12pm – 6pm) / Evening (6pm – 11pm) / Anytime
Wednesday / AM (6am-12pm) / PM (12pm – 6pm) / Evening (6pm – 11pm) / Anytime
Thursday / AM (6am-12pm) / PM (12pm – 6pm) / Evening (6pm – 11pm) / Anytime
Friday / AM (6am-12pm) / PM (12pm – 6pm) / Evening (6pm – 11pm) / Anytime
Saturday / AM (6am-12pm) / PM (12pm – 6pm) / Evening (6pm – 11pm) / Anytime
Sunday / AM (6am-12pm) / PM (12pm – 6pm) / Evening (6pm – 11pm) / Anytime

EMPLOYMENT HISTORY

Please complete the table below starting with your most recent employment, please detail any gaps in employment and continue on a separate sheet if necessary

Dates Employed (From/To) / Job Title / Employer / Brief Description of Duties

EDUCATION OR TRAINING

Please give details of any education or training relevant to the post applied for. Please Include dates, qualifications and places of training, if relevant

SKILLS AND EXPERIENCE

Please give details of any skills or experience you have that may help you to fulfill the job role. Please include any relevant personal experiences, skills or experience gained from voluntary work or hobbies, along with any relevant job related skills and experience

WHY ARE YOU APPLYING FOR THIS JOB?

Please give any further information that you feel may support your application

REFERENCES

Please provide the names and contact details of three people who would be able to give you a reference. At least one should be a previous employer, tutor, or other professional person) and one must be the current or most recent employer.

1.
Name
Capacity in which known (I.e. Employer, Tutor, Vicar etc)
Address
Telephone Number
Mobile number
Email Address
(if known)
2.
Name
Capacity in which known (I.e. Employer, Tutor, Vicar etc)
Address
Telephone Number
Mobile number
Email Address
(if known)
3.
Name
Capacity in which known (I.e. Employer, Tutor, Vicar etc)
Address
Telephone Number
Mobile number
Email Address
(if known)

Can we take up these references before interview? YES / NO

Where did you see the job advertised? ______

DECLARATION

I understand that to knowingly give false information or to omit information will be considered as a breach of trust and could result in my dismissal at any time in the future. I declare that the information I have given on this form is correct.

SIGNED: DATE:

Equal Opportunities

Monitoring Form

We are committed to being an equal opportunities employer. The aim of our policy is to ensure that all applicants are treated equally irrespective of ethnicity, age, disability, gender, language, religion or belief/non-belief or sexual orientation.

To assist in monitoring this policy, and for no other reason please would you complete this questionnaire. This information will be kept strictly confidential.

Please select one or write in if appropriate:

Are you:

·  Male

·  Female

·  Transgender

Would you describe yourself as:

·  British – Welsh, English, Irish, Scottish, Other British

·  Non – British

·  Gypsy/Traveller

·  Refugee/Asylum Seeker (please write in current/last nationality) ______

Can you understand, speak, read or write Welsh? (Please select all that apply)

·  Understand spoken Welsh

·  Speak Welsh

·  Read Welsh

·  Write Welsh

·  Learning Welsh

·  None of these

Which languages do you use from day to day? (Please select all that apply)

·  English

·  Welsh

·  British Sign Language

·  Other (please state) ______

Do you have a long-standing illness, disability or infirmity?

By long-standing we mean anything that has troubled you over a period of time or that is likely to affect you over time. This could also be defined under the Disability Discrimination Act 1995 as ‘Having a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day to day activities’

·  Yes

·  No

What is your religion/(non-)belief even if you are not currently practising?

·  No religion

·  Christian (including Church of England, Catholic, Protestant and all other Christian denominations)

·  Buddhist

·  Hindu

·  Jewish

·  Muslim

·  Sikh

·  Any other religion (please state) ______

·  Prefer not to say

Do you consider that you are actively practising your religion?

·  Yes

·  No

What is you ethnic group?

·  British

·  Any other white background (please state)______

·  Mixed white and black Caribbean

·  Mixed white and black African

·  White and Asian

·  Any other mixed background (please state) ______

·  Asian or Asian British

·  Indian

·  Pakistani

·  Bangladeshi

·  Chinese

·  Any other Asian background (please state) ______

·  Black or Black British

·  Caribbean

·  African

·  Any other African background (please state) ______

·  Other Ethnic group (please state) ______

What is your sexual orientation?

·  Bisexual

·  Gay man

·  Gay woman/lesbian

·  Heterosexual/straight

·  Other

·  Prefer not to say

Are you reasonably fluent in any other language? (please state) ______