Leeds Gypsy and Traveller Exchange Ref: GATE Web

Job Application: Health Advocate

Please indicate if you are applying for the post as a secondment here and give details of your substantive employer, line manager and current position:
Title / Forename / Surname
Address
Post Code
Telephone / Home: / Mobile:
Email

References

Please give names and addresses of two referees. (If possible one should be your present employer or training provider). / Can we contact them before interview?
Name:
Address:
Tel: / Email:
Occupation: / Capacity in which Known:
Name
Address:
Tel: / Fax:
Occupation: / Capacity in which Known:

Education and Professional and Relevant Training

Course / Place Studied / Qualifications Gained / Date
Qualifications currently being pursued:
Expected date of completion:

Voluntary Work

Dates / Place of Voluntary Work / Duties Undertaken

Employment

Present Occupation

Name of Employer:
Address of Employer: / Salary: £
Brief description of principle duties:
Date appointed:
Notice period required:

Previous Employment (in date order from present)

Name of Employer / Date / Position Held
Description of duties / Reason for leaving
From / To

Information in support of your application

Please use this page to state why you want this job and to describe the qualities you would bring to the post. Please

show here how you meet the person specification for the post (use a further sheet if necessary).

Medical Details
How many days absence from work due to illness have you had in the last 2 years
Please give details of any serious illness:
Criminal Convictions
The job you are applying for is one which will give you access to under 18 year olds in unsupervised situations. It is therefore exempt from the provisions of the Rehabilitation of Offenders Act 1974 and you are required to disclose all criminal convictions against you, whether or not these are ‘spent’ under the terms of the Act
Do you have any criminal convictions? / State yes or no
If you have answered Yes to the above question, then please supply, on a separate sheet of paper, the following information about all convictions against you:
Offence for which you were convicted:
Date of conviction: Court in which you were convicted:
Sentence imposed.
It is the policy of Leeds Gypsy and Traveller Exchange not to discriminate on the grounds of criminal convictions, and therefore only convictions which are directly relevant to the job you have applied for will be taken into account.
If your application is successful you will be required to undertake a Disclosure and Barring Service check, for which the Project will pay

Disclosure of information

Please sign and date below to indicate your agreement to the following declaration which applies to all information

provided by you in this application.

I understand that if I am offered the post the information submitted in my application will form a part of my contract

of employment with Leeds Gypsy and Traveller Exchange and that if it is subsequently discovered that I have wilfully

or negligently given false information or withheld information, I will be liable to immediate dismissal and may be

prosecuted. I understand that canvassing directly or indirectly will be a disqualification.

Signature / Date

1