Application Form - Health in Mind

Application Form - Health in Mind

Post Details
Post Applied For: Board Director
Personal Details
Full Name:
Address:
Postcode: / Email Address:
Home Phone:
Mobile Phone:
Work Phone:
(We will not contact you at work without prior consent. To consent please tick this box )
Statement of Experience
Please use this section to describe why you are interested in this role and the skills, interests and experience you could bring. Please consider the role profile in preparing your response.
References
Please provide details of 2 referees. References are sought only in relation to successful candidates. They should not be a relative.
Name:
Address:
Email:
Tel: / Name:
Address:
Email:
Tel:
Qualifications
Please tell us about any relevant qualifications which you hold
Qualification / Date Awarded
Current/Most Recent Employment
Please give details of any relevant employment:
Name & Address of present/most recent employer / dates of employment
Description of your current / most recent job role
Description of any other relevant job roles

Potential Conflicts of Interest

Do you have any business commitments which have the potential to represent a conflict of interest with the post for which you are applying for? If so, please give a brief description
Learning and Development
What have you been doing to keep yourself up to date in your field? Please include CPD activities, formal and informal training and development relevant to this post
Professional Membership & Appointments
Please list any relevant professional memberships or appointments
Have you ever been convicted of a criminal offence, other than a spent conviction under the Rehabilitation of Offenders Act 1974? If Yes, please provide details:
Note to all applicants
Please do not include any additional material with your application unless this has been requested. This does not include any continuation sheets from this application.
If invited to interview you will be asked to sign your application form and the following declaration.
Declaration
I declare to the best of my knowledge the information given on this form (and any additional sheets used) is true and correct. I confirm that have not been disqualified as a Director under company law or as a trustee under charity law and am eligible to serve on the Health in Mind Board. I realise that false information or omissions may lead to my application being disqualified, or if I have already been appointed, that appointment may be revoked.
I understand that if appointed:

• I must declare if I have any interests in any company or charity that deals with Health in Mind
• I am over age 18.
• I am not an undischarged bankrupt.
• I have not previously been removed from trusteeship of a charity by a court or the charity commissioners.
• I am not under a disqualification order under the Company Directors’ Disqualification Act 1986.
• I am, in the light of the above, not disqualified by Part 1 of the Law Reform (Miscellaneous Provision) (Scotland) Act 1990, from acting as a charity trustee.
• I undertake to fulfil my responsibilities and duties as a trustee of Health in Mind in good faith and in accordance with the law and within Health in Mind’s objectives, vision and values.
• I do not have any financial interests in conflict with those of Health in Mind (either in person or through family or business connections) except those which I have formally notified in a conflict of interest statement. I will specifically notify any such interest at any meeting where trustees are required to make a decision which affects my personal interests, and I will unless agreed otherwise absent myself entirely from any decision on the matter and not vote on it.

You will be asked to sign this declaration should you be invited to interview.

EQUALITY AND DIVERSITY MONITORING

Health in Mind is an Equal Opportunities Employer. We actively encourage applications from all sectors of the community.

In order to ensure our Equal Opportunities Policy is operating effectively, we would be grateful if you would complete the following pages fully. This information you provide in the first 3 pages is for monitoring and administration purposes only and will not be used in any part of the selection process.

In compliance with the Data Protection Act, Health in Mind will treat all information contained within this form as confidential. No information will be divulged to other parties and will be used only for those purposes expressed. It is also Health in Mind policy to destroy all materials relating to the recruitment process four months after the appointment has been made or notification of the unsuccessful candidate/s, if later.

Post applied for: ______Board Director ______

ETHNICITY

What is your ethnic group? Choose one section from A to E, then tick one box which best describes your ethnic group or background.

AWhite

Scottish / English / Welsh
Northern Irish / British / Irish
Gypsy /Traveller / Polish
Any other white ethnic group, please write in ______

BMixed or multiple ethnic groups

Any mixed or multiple ethnic groups, please write in ______

CAsian, Asian Scottish or Asian British

Pakistani, Pakistani Scottish or Pakistani British
Indian, Indian Scottish or Indian British
Bangladeshi, Bangladeshi Scottish or Bangladeshi British
Chinese, Chinese Scottish or Chinese British
Other, please write in ______

DAfrican, Caribbean or Black

African, African Scottish or African British
Caribbean, Caribbean Scottish or Caribbean British
Black, Black Scottish or Black British
Other, please write in ______

EOther ethnic group

Arab
Other, please write in ______
I do not wish to disclose this information

Please complete both sides of the form

AGE

Date of Birth ______/ Rather not say

GENDER

Male / Female
Transgender / Rather not say
Other, please write in ______

DISABILITY

The Equality Act 2010 defines disability as a physical or mental impairment which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities.

Do you consider yourself to have a disability according to the above definition?

Yes / No / Rather not say

RELIGION AND BELIEF

Which group below do you most identify with?

No religion / Baha’i / Buddhist
Christian / Hindu / Jain
Jewish / Muslim / Sikh
Other, please write in ______/ Rather not say

SEXUAL ORIENTATION

How would you describe your sexual orientation?

Bisexual / Gay man / Heterosexual or ‘straight’
Lesbian / Rather not say
Other, please write in ______
Health in Mind
Website / Health in Mind
Contact / Newspaper
Recruitment website / Publication / Other (please state)

SOURCE

How did you learn of this vacancy?