Complete in black ink or type.
Please use attached guidance to complete the form.
Note: applications will not be considered if you do not answer all the questions
Section 1 – Contact Details / Post applied for:
Mr/Mrs/Miss/Ms / First Name(s): Surname:
Address:
Post Code: / Home telephone number:
Daytime telephone number:
Mobile telephone number:
Contact e-mail:
Work Permit/Visa
Have you got a Work Permit/Visa to work in this country? / Yes / No
Work permit/Visa No: / DD/MM/YEAR
Expiry date
Please note that evidence of your work permit will be required at interview.
Driving Licence
Do you hold a current full driving licence? / Yes / No / Do you own a car? / Yes / No
Registered Disability
Are you a registered disabled person? / Yes / No
If yes, please tell us what we need to do if you are short-listed, in order to accommodate this at the interview:
Section 2– EDUCATION (Continue on separate sheet if necessary)
)
Secondary Education
Schools attended / From / To / Qualification(s) Gained including grade
Further Education (Full-time)
University/College / Subject Studied / From / To / Degree/Diploma obtained
Professional/Trade qualifications
Qualification / Examining Body / From / To / Date Membership
Certificate gained
Other Studies, part-time/evening/correspondence courses etc
Subjects / Examining Body / From / To / Results with dates
Section 3 – Employment Record
Post applied for:
Present or most recent employer / From: / To:
Employer’s Name and Address: / Annual Salary
Other Benefits
Reason for leaving
Notice period
Position held and brief description of duties:
Previous Employers (most recent first): Due to new CQC changes you will need to give your full employment history since leaving school. If you require extra space please attach an additional sheet.
Employer’s Name & Address / Position(s) Held / From / To / Reason for leaving
Voluntary Work
Organisation / Activity / Duties / Length of time involved with this organisation.
Gaps in Employment:If your employment history has any gaps, please ensure you clearly identify the dates and provide information that clarifies the situation e.g. unemployed, travelling, parenting years etc. (Continue on separate sheet if necessary)
Date From / Date To / Explanation
Section 4 – Supporting Statement
Please tell us about any skills, abilities and experience you consider to be relevant to this position taking care to relate to the person specification provided for this post.(You may use a continuation sheet if necessary)
Section 5 – References
Please give the full name and address of two persons, one of whom must be your present or most recent employer from whom confidential references may be obtained. Your employer will not be approached without your consent.
Can your employer be approached before the interview? YES/NO
Current/Most Recent Employer / Previous Employer/Personal Acquaintance (not family member)
Name: / Name:
Job Title: / Job Title:
Relationship: / Relationship:
Address:
Post Code: / Address:
Post Code:
Email Address: / Email Address:
Tel: / Tel:
Section 6- Rehabilitation of offenders Act 1974 – Declaration of Criminal Offences
Please note that the position you are applying for is exempt from the Rehabilitation of Offenders Act 1974. You should therefore disclose if you have any convictions or cautions for criminal offences. Spent convictions must be disclosed as checks against police records will be made (Read attached note).
Have you ever been convicted of a criminal offence, cautioned or been the subject of a conditional discharge or probationary order? / Yes / No
If yes please give details(Use separate sheet if necessary)
Section 7 – Data Protection Declaration
Under the terms of the Data Protection Act 1998 the information you provide in this application form and recruitment monitoring form will only be used for the purpose of assessing your suitability for employment, for monitoring DGSM yourChoice policies and procedures and human resource management purposes.
If you are unsuccessful this information will be retained on file for at least 6 months. The information may be used in internal proceedings to consider a complaint about the selection process and / or to defend DGSM yourChoice against a legal challenge to the fairness of the selection process from any interested party..
I understand the information above and hereby
  1. Declare that the information provided in this application form and monitoring form is correct to the best of my knowledge and belief. I understand that any false statements on this form will justify withdrawal of an offer of appointment or my dismissal from DGSM yourChoice..
  2. Agree that the information I give to DGSM yourChoice in connection with this application for employment may be stored and processed for the purposes stated above.
  3. Consent to DGSM yourChoice undertaking any checks it may deem necessary in connection with my application.
  4. Agree to DGSM yourChoice asking my previous employers questions regarding my sickness and disciplinary record and give my consent for my previous employers to disclose this information.
Signed: Date:

Approximately 200 babies are born every week with a learning disability

To ensure that DGSM yourChoice
is able to continue supporting people with learning disabilities
develop into adulthood and as adults, we need your help.

You can help by:

Making a donation

Becoming a Member of DGSM yourChoice

Holding a fundraising event or supporting our events

Volunteering with us

Leaving DGSM yourChoice a gift in your will

Donating to our charity shop

For further information, please contact us on:

Tel: 01322 281833

Fax: 01322 286633

or email

Registered Office

53 Highfield Road, Dartford, Kent DA1 2JS

Affiliated to Royal Mencap Society

Printed by: Peppercorns Project

DGSM yourChoice, 3 Orchard Street, Dartford, Kent. DA1 2DF

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