Details of all our vacancies are provided on

/ Pippbrook
Dorking, Surrey, RH4 1SJ
Tel: (01306) 879109
EMAIL:
Office use only
APPN NO:

PLEASE NOTE THAT TO ENSURE COMPLIANCE WITH OUR EQUAL OPPORTUNITIES POLICY C.V.s

CANNOT BE ACCEPTED. TO ALLOW FOR PHOTOCOPYING PLEASE COMPLETE IN BLACK INK.

CONFIDENTIAL

APPLICATION FOR THE POST OF:

PERSONAL DETAILS

ADDRESS:

TELEPHONE NUMBERS (include STD code):

HOME
WORK
MOBILE
EMAIL
Schools, colleges and universities attended / From / To / Qualifications gained (evidence will be required)
Membership of professional bodies: / Dates:
Other relevant training: / Dates:
Please answer if appropriate:
Do you have a current full driving licence?
YES NO / Does your licence have any endorsements for motoring offences?
YESNO / During the past 5 years have you been convicted of any motoring offences?
YESNO
If yes, how many points are within 3 years? / Have you ever been refused motor vehicle insurance or continuance thereof?
YESNO

PRESENT (OR MOST RECENT) EMPLOYMENT:

Job Title: / Dates from/to:
Employer’s name and address: / Present Salary: £
Max Salary: £
Notice required:
Description of duties and responsibilities (continue on another sheet if necessary):
Reason for leaving
Position in organisation:
To whom are you responsible (Job Title)?
Do you regularly supervise other staff?
If so, please give numbers and description / YESNO
Please state briefly your reasons for applying for this post with Mole Valley.

PREVIOUS EMPLOYMENT (Starting with the most recent):

Name and address of Employer: / From:
To:
Salary £ / Job Title & description of duties:
Reason for leaving:
Name and address of Employer: / From:
To:
Salary £ / Job Title & description of duties:
Reason for leaving:
Name and address of Employer: / From:
To:
Salary £ / Job Title & description of duties:
Reason for leaving:
Name and address of Employer: / From:
To:
Salary £ / Job Title & description of duties:
Reason for leaving:
Name and address of Employer: / From:
To:
Salary £ / Job Title & description of duties:
Reason for leaving:
By reference to the person specification, please outline details of your experience, skills, responsibilities and achievements, including voluntary or community based activities, which provide evidence of your suitability for this post.
Minimum salary requirement (if any):
National Insurance Number:
How did you find out about this vacancy?

REFEREES:

Names and addresses of 2 persons whom the Council may apply for references. One should be from your present, or most recent, Employer. (References will only be sought following interview).
1. / 2.

DECLARATION:

I declare that the information supplied is true and that I have not canvassed Members or Officers of Mole Valley District Council and will not do so. I also understand that certain personal information will be gathered in connection with this application.

We will process personal information contained in this form to comply with the requirements of the Data Protection Act 1998 and the Commission for Racial Equality. It will be processed by computer as required by the Authority for the operational, managerial and associated purposes relevant to the maintenance of a personnel system and payment of remuneration and pensions due. Data will also be used to produce depersonalised statistics. Under the Act you are entitled to request, in writing and with the appropriate fee, copies of certain information we hold about you.

Forms completed by unsuccessful candidates will be destroyed within 6 months.

Signature: / Date:

WHEN COMPLETED THIS FORM SHOULD BE RETURNED TO HUMAN RESOURCES AT PIPPBROOK.


EQUALITY AND DIVERSITY MONITORING FORM

The Council is committed to ensuring that all appointments are made on merit, irrespective of gender, marital status, race or disability. To enable that to be monitored, you are requested to complete this form and return it with your application. It will not be released to staff involved in short-listing and will not form part of your application.

Full name:
Preferred First Name:
Title: Mr/Mrs/Miss/Ms/Dr/Other (please specify)
Post applied for:
  1. Gender – are you
/ MaleFemale
2. Date of Birth / / /
3. Marital Status – would you describe yourself as / Married in a Civil Partnership
Single Divorced Separated
  1. Ethnic Origin – to which of the following groupswould you say you belong?
/ White: British
White: Irish
White: Other White
Mixed: White and Black Caribbean
Mixed: White and Black African
Mixed: White and Asian
Mixed: Other Mixed
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Bangladeshi
Asian or Asian British: Other Asian
Black or Black British: Caribbean
Black or Black British: African
Black or Black British: Other Black
Chinese or Other Ethnic Group: Chinese
Chinese or Other Ethnic Group: Other Ethnic Group
  1. What is the basis on which you are entitled to take up employment within the UK?
Can you produce evidence to support this? YES/NO
  1. Do you consider yourself to be disabled as defined by the Equality Act? The Disability Discrimination Act defines ‘a disabled person’ as a person with ‘a physical or mental impairment which has a substantial or long-term adverse effect on their ability to carry out normal day-to-day activities’
/ YES NO If yes please give details
  1. Relationships – to the best of your knowledge are you related to any Officer or Member of the Council? (If yes please give details.)
/ YES NO
  1. Have you ever been convicted of a criminal offence? If yes, please give details including date, nature of offence and sentence.
(Note: You must declare any unspent convictions. There is no obligation to disclose convictions that are spent under the terms of the Rehabilitation of Offenders Act 1974 unless the post for which you are applying is exempt (detailed on Job Description), in which case you are required to declare all convictions. If you declare a conviction it does not necessarily mean you will not be appointed to the post. A main consideration will be whether the offence would make you unsuitable for the type of work to be done). / YES/NO

Please return this completed form with your application to Human Resources.

If you have any difficulties in completing this form please contact the HR Department on (01306) 879109.