PSB/BCIL application no:

Please complete fully and clearly, ticking/deleting as appropriate.

1. Personal details

Name:

Address:

Post Code:

Daytime Contact Number: Evening Contact Number:

Email:

2. Health

Do you have a health problem or disability so that you require assistance at interview/with the application process? YES/NO

If yes, please give details:

Do you wish to claim a guaranteed interview under the Two Ticks criteria if you meet the minimum criteria for the post? YES/NO

If yes, please give details:

3. Referees

Please give details of two people willing to act as referees for you. They cannot be family members and one of them should be your current or most recent employer.

Name: Name:

Organisation: Organisation:

How do they know you? How do they know you?

Address: Address:

Tel No: Tel No:

Email: Email:

May we contact before interview? YES/NO May we contact before interview? YES/NO

4. Present or most recent employment/or details of organisation where you volunteered

Job title:

Employer’s name and address:

Dates:

Notice period required:

Key duties:

Salary:

Reason for leaving:

5. Previous employment/volunteer experience:

Please give details of your previous employment history. Please continue on up to ONE additional page.

Employer’s name and address

/ Dates /

Job Title & key duties

/

Reasons for Leaving

6. Education and Qualifications

Please give details of relevant education and qualifications achieved.

Please add rows if required.

Establishment

/

From - To

/

Qualifications

7. Training

Please give details of any relevant vocational or professional training, short courses, on the job training, mentoring etc.

Please add rows if required.

Dates

/

Title and brief description of course/training programme

8. Other relevant skills and/or professional qualifications and memberships

Please specify

9. IT skills

Please complete as indicated by * and tick as applicable. If you have knowledge or other or more than one programme, please add these under “programme details”

application / programme details / advanced / competent / basic
Word processing / Word
spreadsheets / Excel
databases (* - pls specify) / *
email / Outlook Exchange
presentations/DTP / PowerPoint

10. Experience and understanding of how common mental health problems can create social isolation

Please provide a brief overview of your experience and/or your understanding of the barriers that disabled people face, in no more than 200 words. Please do not exceed the word limit.

11. Supporting statement

Please give details of your relevant skills, experience and knowledge in the following areas, whether gained in a paid or voluntary capacity. Please ensure you refer to the job description and person specification. Please continue on up to TWO additional pages if necessary.

11.1 Experience of providing supervision to staff or volunteers. If you do not yet have this experience, outline the personal qualities which you think would make you successful as a supervisor.

11.2 Experience of delivering good customer service

11.3 Understanding of independent living philosophy and the social model of disability

12. Work Permit

Do you require a permit to work in the UK? YES/NO

If yes, when does your current permit expire?

13. Convictions

Do you have any criminal convictions? YES//NO

If yes, are they spent? YES/NO

14 Travel

Are you able to travel across the borough? YES/NO

What means of transport do you use?

15 Job share

Would you be interested in job-sharing? YES/NO

Is job-sharing your preferred option? YES/NO

If you would be interested in a job-share, how many hours would you be prepared to work? Please indicate all that apply.

6 12 18

16. I confirm that the information I have given in this application form is true and accurate. I consent to the use of this information for considering my application and understand that:

·  It will be treated confidentially at all times.

·  If my application is successful, the information will form part of my personal records.

·  If my application is unsuccessful, the information will be destroyed after six months.

·  I also consent to an Enhanced Criminal Records check if the post involves working with

children/young persons/vulnerable adults.

Signed: Date:

Please return this application form to Caroline Collier at by 5pm, Thursday 23rd June 2016.