Application Form

Post Applied For______

Please fill in all this application form, do not “refer to C.V” (use additional sheets if required)

Surname / Forenames / National Insurance No
Address
Post Code / Telephone No
e-mail: / Mobile:

General/Further Education Details of qualifications (please note that we may verify all qualifications)

Qualifications

/

Awarded by

/

Dates

Technical, Professional or Occupational Training, Apprenticeship etc.

Dates
From/To / Type and Location of Training / Qualifications Gained
State membership of any professional institution / Type of Membership / Date Status granted

Present position (or most recent)

Company / Date Joined
Address / Starting Salary £ P/AP/W
Fringe benefits
Current salary £ P/A P/W
Nature of Business / Department
Total employed in company / Job title
Please describe briefly your present (or most recent) position. The person you reported to and for whom you were responsible. What are your main responsibilities and activities? Please mention what you consider to be your main contribution to this position and why.
Please outline how your knowledge, experience, competencies and personal attributes match those outlined in the job description for this post.

Full Career History (excluding current or most recent position)

Dates

From/to / Company, Location
& Nature of business / Position held & main responsibilities / Salaries
Starting / end / Reasons for leaving

Continue on a separate sheet if necessary

Supporting Statement.

Please state here what special skills, abilities and experience you would bring to the position applied for and why you would make a particularly suitable candidate.
Do you consider yourself to have a Disability / Yes /
No
Do you suffer from any medical condition, which may affect your performance in the job?
Which level of Disclosure Scotland check do you currently hold? Please tick;
Basic Disclosure
Enhanced Disclosure
PVG Scheme Membership
None of the above
Do you hold a Full Driving licence? / Yes / No / Do you have any Current Endorsements? / Yes / No
If you have any current endorsements, please give details
How did you learn of this vacancy?
Have you applied to this organisation before? Yes / No
If Yes please give details, dates
Other information
What are your main hobbies and interests? (Give details of memberships of any clubs, offices held, etc)

What period of notice do you have to give______

Name of referees, one must be present or most recent employer, and one a past employer.

(No enquires will be made to present employer without your permission)

Name / Address
Tel No / Position in company
Name / Address
Tel No / Position in company
Name / Address
Tel No / Position in company
Rehabilitation of Offenders Act 1974. Because of the nature of the work for which you are applying, this post is exempt from the provisions of section 4 (II) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of offenders act 1974 (Exceptions) order 1975 and you are therefore not entitled to withhold information about convictions which for other purposes are spent under the provisions of the act and in the event of employment, any failure to disclose any convictions could result in dismissal or disciplinary action.
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE, OR ARE YOU AT PRESENT THE SUBJECT OF CRIMINAL CHARGES? YES / NO
IF YES, PLEASE GIVE BRIEF DETAILS ON A SEPARATE SHEET, and enclose in an envelope for
the attention of HR Dept, marked STRICTLY PRIVATE
Declaration: I declare that the statement I have made with regard to this application is to the best of my knowledge true and complete. I understand that the Organisation reserves the right to withdraw any offer of employment or to terminate any employment already commenced if the information given by me is inaccurate in any way. I also understand that any offer of employment is subject to satisfactory references and other checks, which may have to be conducted, such as enhanced disclosure (police checks) from Disclosure Scotland, and I give my consent for the organisation to carry out such checks.
Signed Date


Equality Opportunities Monitoring

Momentum Scotland wants to meet the aims and commitments set out in its equality policy. This includes not discriminating under the Equality Act 2010, and building an accurate picture of the make-up of the workforce in encouraging equality and diversity.

The organisation needs your help and co-operation to enable it to do this, but filling in this form is voluntary.

The information you provide will stay confidential, and be stored securely and limited to only some staff in the organisation’s Human Resources section. Forms completed by candidates will be separated from job applications on receipt and will be used to provide statistical information for monitoring purposes, and will be treated in the strictest confidence. It will not be made available to anyone involved in the recruitment process. Forms from unsuccessful applicants will be securely disposed of after 6 months. This is in line with data protection legislation and the Equalities Act 2010.

Staff should please return the completed form in the envelope provided.

Gender Male * Female * Non-binary * Prefer not to say * If you prefer to use your own term, please specify here

Are you married or in a civil partnership? Yes * No * Prefer not to say *

Age 16-24 * 25-29 * 30-34 * 35-39 * 40-44 * 45-49 *

50-54 * 55-59 * 60-64 * 65+ * Prefer not to say *

What is your ethnicity? Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box

White

English * Welsh * Scottish * Northern Irish * Irish *

British * Prefer not to say *

Any other white background, please write in:

Mixed/multiple ethnic groups

White and Black Caribbean * White and Black African * White and Asian * Prefer not to say * Any other mixed background, please write in:

Asian/Asian British

Indian * Pakistani * Bangladeshi * Chinese * Prefer not to say *

Any other Asian background, please write in:

Black/ African/ Caribbean/ Black British

African * Caribbean * Prefer not to say *

Any other Black/African/Caribbean background, please write in:

Other ethnic group

Arab * Prefer not to say * Any other ethnic group, please write in:

Do you consider yourself to have a disability or health condition?

Yes * No * Prefer not to say *

Do you have a disability as defined by the Equalities Act 2010? “A physical or mental impairment which has a substantial and long-term adverse effect on their ability to perform day-to-day activities”

Yes * No * Don’t know *

What is the effect or impact of your disability or health condition on your ability to give your best at work? Please give details here:

The information in this form is for monitoring purposes only. If you believe you need a ‘reasonable adjustment’, then please discuss this with your manager, or the manager running the recruitment process if you are a job applicant

What is your sexual orientation?

Heterosexual * Gay woman/lesbian * Gay man * Bisexual *

Prefer not to say * If you prefer to use your own term, please specify here:

What is your religion or belief?

No religion or belief * Buddhist * Christian * Hindu * Jewish *

Muslim * Sikh * Prefer not to say * If other religion or belief, please write in:

What is your current working pattern?

Full-time * Part-time * Prefer not to say *

What is your flexible working arrangement?

None * Flexi-time * Staggered * Term-time hours *

Annualised hours * Job-share * Flexible shifts * Compressed hours *

Homeworking * Prefer not to say * If other, please write in:

Do you have caring responsibilities? If yes, please tick all that apply

None * Primary carer of a child/children (under 18) *

Primary carer of disabled child/children *

Primary carer of disabled adult (18 and over) * Primary carer of older person *

Secondary carer (another person carries out the main caring role) *

Prefer not to say *

Forms from unsuccessful applicants will be securely disposed of after 6 months. This is in line with data protection legislation and the Equalities Act 2010.

HR: Recruitment / HR13
TITLE: Application form / Date: March 2017
Page 7 of 7
Issue 1 – 1st Review