APPLICATIONFORM
PRIVATEANDCONFIDENTIAL
POSITIONAPPLIEDFOR:
Ifyouarefillinginthisformbyhand,pleaseuseblackinkortypescripttofacilitatecopying.Youmayuseadditionalsheetsofpaperifthereisnotenoughspacetoenterrelevantinformationinanysectionoftheform.
1.PERSONALINFORMATION
Surname(blockletters): / Name:
HomeAddress: / HomeTelephone No:
Postcode: / MobileTelephoneNo:
NationalInsuranceNumber: / E-mail Address:
Maywe,withdiscretion,telephoneyou at work?YES/NO
For officeuse only:
Acknowledged:...... …… / Short-listed: YES/NO / Appointed:YES /NO

2.EDUCATION,TRAININGSKILLS,INSTITUTEMEMBERSHIPS

(You maybe askedtoprovideproof of yourqualificationsas aconditionof employment)

Secondary Schools,CollegesandUniversitiesattended / Dates / Qualificationsgainedorpending(statesubjectswith grade,level orclass)
From / To
Trainingcourses,developmentalcoursesorGovernment trainingschemes / From / To / Qualificationsgainedor pending
Non-vocational experiences/skillswhich mayberelevantto your application(e.g.familyduties,voluntarywork,FirstAidandleisureinterests) / From / To / Qualificationsorcertificatesgained
MembershipofProfessionalBodies / From / To / Grade ofmembershipandifbyexamination orelection
Languages(includingsignlanguageInterpretation) / Level oflanguage skills

3.PRESENTORMOSTRECENTEMPLOYMENT

Post title:
Nameandaddress ofemployer:
Postcode:
Telephonenumber with STD code: / Dateappointed:
Periodofnoticerequiredtoterminate:
Leavingdateandreasonforleaving:
Current wage/salaryandPublicSectorgrade: (ifapplicable):
Pleasegiveabriefdescriptionofyourdutiesandactivities,includingyourresponsibilities,accountabilityandachievements.Inaddition,ifapplicable,pleasestatethereasonwhyyouwouldliketochangeyourjob.Ifyouareunemployedoryouareaschoolorcollegeleaver,describeanyexperience orachievementsthat youfeel arerelevant.Includevoluntary, sparetimeorprojectwork.

4.EMPLOYMENTHISTORY(includingrelevantvoluntarywork)

Previousemploymentsinceleavingschool,indateorderwiththemostrecentpositionfirst.Pleaseaccountforanygapsinyouremployment(subjecttotheprovisionsrelatingtodisclosureundertheRehabilitationofOffendersAct1974).Pleasecontinue on aseparatesheetifnecessary.

Dates / Nameandaddress ofemployer / Job titleplusbriefdescriptionofresponsibilities,reasonforleavingandsalary
From / To

5.SUPPORTINGSTATEMENTS

Please state whatattractedyou to applyfor thispost,relatingyourexperience,skillsandattributesto theenclosedpersonspecification/jobdescriptions.Pleaseincludeanyotherinformationwhichyoufeelisrelevanttoyourapplication.Youmaychoose toanswer thissection on separatesheets.

6.OTHERINFORMATION

(Pleaseanswerthe questionsby circlingordeletingYESorNOandgivingtherequireddetails)

MedicalHistory / Isyourhealthgenerallygood?YES/NO
Haveyouconsultedyourdoctorinthepastyear?YES/NO
If‘yes’givedetails:
Howmanydayssick leavehave youtakeninthelast2 years?
(Thoseinvitedforinterviewarerequiredtocompleteamedicalquestionnaire)
ParentalLeave / Pleaseindicatehowmanydays(ifany) youhavetakenasparentalleavepereligiblechild:
AuthorisationToworkinThe
UnitedKingdom / Doyouhaveevidenceof yourentitlementtoliveandwork intheUK?YES/NO(Forexample,aNationalInsurancenumber,abirthcertificateissuedintheUKorRepublicofIrelandorapassportconfirmingBritishCitizenship)
DoyouneedaworkpermittoallowyoutoworkintheUK?YES/NO
(Thoseinvitedforinterviewarerequiredtoproduceconfirmatoryevidence)
PreviousConvictions / Haveyoueverbeenconvictedofacriminaloffenceorbeeninvestigatedorconvictedforfraud?YES/NO
IfYESpleaseprovidedetailsonseparatesheet
(YouarenotrequiredtodiscloseconvictionswhicharespentundertheRehabilitationofOffendersAct,unlessthepostforwhichyouhaveappliedforisexemptundertheAct)TheCouncilmayrequireyoutoconsenttoaCriminalRecordsBureaudisclosureasaconditionofyouremployment.Youneednotincludemotoring
offencesunlessyourlicencehasacurrentendorsementasaresultofaconviction)
TransportArrangements / DoyouholdacurrentfullUKDrivingLicence?YES/NODoyouhave yourowntransportwhichwouldbeavailableforCouncil YES/NObusiness?
Disability / Do you consider yourself to have any disabilitythat might require the Council to makeadaptationsinorderforyoutoattendinterview? YES/NO
If‘yes’,pleasegivedetails:
SpareTimeActivities / HaveyouanyobligationsinrespectoftheTerritorialArmyorReserveForcesortheFireBrigade?YES/NO
If‘yes’,pleasegivedetails:
Pleasegivebriefdetailsofyourleisureactivities,sports,hobbies,interests,etc.
Relationships / Doyouhaveapersonalrelationshipwith,orareyourelatedtoanymemberofstaffortoanelectedChippenhamTownCouncillor? YES/NO
If‘yes’,pleasegivedetails:
JobShare / Are youinterestedinbeing partofajobsharescheme(ifavailable)?YES/NO

7.REFERENCES

Pleasenominatetwopersonstowhomwecanapplyforreferencesconcerningyoursuitabilityforthispost.Oneshouldbeyourpresentemployeror,ifnotapplicable,yourlastemployer.Theothershouldpreferablybeapreviousemployer.Ifyouareaschool,collegeoruniversityleaver,yourheadteacheror tutorshouldbe nominated. PLEASEPRINTTHEDETAILS
Name:JobTitle:Address:
DaytimeTelephoneNo:Relationship: / Name:JobTitle:Address:
DaytimeTelephoneNo:Relationship:
Ifyou areshort-listedfor interview,may wecontactyour refereesbeforetheinterview?
Referee1:YES/ NO / Referee2:YES/ NO
Availabilityfor interview / DateswithinthenexttwomonthswhenyouwouldNOTbeavailableforinterview(ifapplicable)

8.DECLARATION

IunderstandthatallformsofcanvassingofanyCouncillorsorstaffofChippenhamTownCouncilinconnectionwiththisappointmentwillautomaticallydisqualifyme.IdeclarethatalltheinformationIhavegivenis,tothebestofmyknowledgeandbelief,trueandaccurate.Iacceptthatany falsestatementmaydisqualify me fromemploymentorrendermeliableto summarydismissal,andthatImay havetoproducedocumentaryevidenceofmyqualificationsandprevioussalary.Furthermore,Ihavenotomittedanyfactswhichmayhaveabearingonmyapplicationforemployment.Ialsounderstandthatnoofferofemploymentmadetomewillbebindingunlessconfirmedinwriting.IgiveexplicitconsentthattheinformationwhichIgiveonthisformmaybeprocessedinaccordancewiththeCouncil’sregistrationunder the DataProtectionAct 1998.

Signed:Date:

Pleasereturnyourcompletedapplicationform inanenvelopemarked“CONFIDENTIAL” to:

Recruitment

Chippenham Town Council

TownHall,

HighStreet,Chippenham,

Wiltshire, SN153ER

Or you can email it to:

EQUAL OPPORTUNITYMONITORINGCONFIDENTIAL

ChippenhamTownCouncilisanequalopportunityemployerandaimstoensurepeoplearerecruited,selected,trainedandpromotedonthebasisofjobrequirements,skills,abilitiesandothercriteria.TheCouncilwillensurethatnojobapplicantoremployeereceiveslessfavourabletreatment on thegroundsof race,colour, nationality, ethnicor nationalorigins,sex,marital status, sexuality,disability orage.Noapplicantwillbedisadvantaged,byconditionsorrequirements,whichcannotbeshowntobejustifiedasbeingnecessaryforthe proper performanceof thejob.

Whenyouhavecompletedthisquestionnaire,pleasedetachandfoldinhalf,andreturnwithyourapplicationform.Theinformationfromthisformwillbetreatedasconfidentialandnotformpartoftheselection process.

Post Title:Post No:n/a

Surname:……………………………………………………………..………Forenames(infull)……………………………………………..Date of Birth:………………………………….. Age…………… (years) Numberofdependants:……………………...……………….(pleaseindicatein theboxesbelowasappropriate)

GENDER / Male / Female
MARITALSTATUS / Single / Married / Livingwithpartner / Separated
Divorced / Widowed
NATIONALITY / British / Irish / Other / (pleasespecify) / ……………….………

OtherEuropeanCountriesinthe EU(please specify)………………….……

ETHNIC ORIGIN

Which ofthe followinggroups bestdescribesyourethnicorigin (please tickoneboxonly)

WhiteBlack or BlackBritish

BritishCaribbean

IrishAfrican

Anyother whitebackgroundAnyother blackbackground

(pleasespecify)………………………………………..………(pleasespecify) …………….……………………….…..…………..……

Asian or AsianBritish / Mixed
Indian / Whiteand BlackCaribbean
Pakistani / Whiteand BlackAfrican
Bangladeshi / Whiteand Asian
Anyother Asianbackground / Anyothermixedbackground
(pleasespecify)……………………………………………………(pleasespecify) ………………………………………….………………...

Chineseor other ethnicgroup

Chinese

Otherethnicgroup

(pleasespecify) ……………………………………………….……

DISABILITY

ChippenhamTownCouncilseekstomakereasonableadjustmentstotheworkenvironmentandworkpracticeto promotethe employmentofpeoplewithdisabilities.

Thedefinitionofdisability,asoutlinedintheDisabilityDiscriminationActs19952005statesthat“apersonhasa disabilityforthe purposeofthe Actifhe/shehasa physical ormentalimpairmentwhich has asubstantialandlong-term adverseeffect on his/’herabilitytocarryout normal day-to-dayactivities”.

Doyouhave adisabilityyouwould like totell usabout? Yes/NoNatureofdisability

…………………………………………………………………………………………………………………………………

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