Confidential

Application Form

(Can be submitted via audio cassette/email. Also available in large type)

Application for the post of…………………………………………………………………………….
Where did you hear of this vacancy?………………………………………………………………….
  1. PERSONAL DETAILS:
Last Name:
Evening Telephone:

Email: / Mr / Mrs / Miss / Ms /other
First Names:
Daytime Telephone:
(can we contact you at work Yes/No?)
Time when available:
Address:
Postcode:
2. EDUCATION (Most recent first)
Dates:
FromTo / Schools, Colleges, Universities
(Name and Address) / Formal Qualification Obtained
(Degree, A Level, NVQ etc)
3. VOCATIONAL QUALIFICATION AND TRAINING:
(Please list vocational qualifications and training undertaken which are relevant to this post)
Courses and Qualifications:

Details of memberships of any technical/professional associations:
Please list any foreign languages spoken and level of competence:
4. EMPLOYMENT RECORD (Start with most recent position)
Dates:
FromTo / Employer/Organisation
Name & Address / Job Title / Reason for leaving and final salary
5. SUPPORTING STATEMENT - Two pages
Please read the person specification carefully and identify relevant skills, experience and abilities against the appropriate selection criteria.
SUPPORTING STATEMENT Continued
6. REFERENCE:
Please give the name and address of two people who can provide an assessment of your suitability for this post. One should be your current or most recent employer.
Name:
Address:
Telephone Number:
Capacity in which known to you.
......
......
Can we contact them prior to interview? Yes/No / Name:
Address:
Telephone Number:
Capacity in which known to you.
......
......
Can we contact them prior to interview? Yes/No
7. FURTHER INFORMATION:
  • Please give details of any dates between when you will not be available for an interview ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • Full driving licence Yes/No?
  • Endorsements Yes/No?
If yes give dates and details ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
  • Are you able to fly abroad if required Yes/No?
  • Do you hold a UK passport Yes/No?
  • Are you willing to work overtime and weekends if required Yes/No?
  • Have you ever worked for BIBIC before Yes/No?
  • Are you related to any BIBIC employee or Trustee Yes/No?

8. SICKNESS ABSENCES
Please detail all sickness absences in the last 2 years, dates and reasons:
Date / Sickness
NOTE:
If you knowingly give any false information, or withhold any information, if you have been appointed, this may lead to your appointment being withdrawn or to dismissal.
If you are made a job offer, BIBIC reserves the right to confirm the basis of any information brought to its notice, relevant to this application. This will include approaching any former employers, whether or not proposed as referees.
All information will be kept in accordance with the requirements of the Data Protection Act 1984.
DECLARATION:
I declare that to the best of my belief, the above information is correct.
I agree to undertake a medical examination by a GP if necessary, and a Criminal records Bureau check. Our written policy on the recruitment of ex-offenders is available on request, as is the Criminal Records Bureau Code of Practice.
I agree that any offer of employment will be subject to satisfactory references.
Signature of Applicant ...... Date ......
The exemptions to the Rehabilitation of Offenders Act 1974 require that all spent or unspent convictions must be declared by applicants for posts within BIBIC. You may, therefore, also be required to undergo a Criminal Records Bureau check and to reveal the results of this check to BIBIC. We will not use information obtained through any of the available certificates to discriminate unfairly against those with convictions irrelevant or unrelated to the application in hand. (In this instance BIBIC will refund to you the fee payable for such a check).
Child sex offenders will never be given a job at BIBIC, but all other convictions will be given careful consideration in the context of the overall application and will not automatically disqualify the candidate from being appointed.
You are requested to put the declaration (please see separate sheet) in a sealed self-addressed envelope with your name on the front. You are also required to complete the attached “Safeguarding Children and Young People” form and place in the same sealed envelope. It will only be opened if you are at the point of being short-listed. All others will either be destroyed by us without opening or if you wish to have the envelope returned intact to show it has not been opened then you need to enclose a stamped addressed envelope.
DECLARATION OF CONVICTIONS
Have you ever been convicted of a criminal offence? Yes/No
(Declaration subject to the Rehabilitation of Offenders Act 1974)
Are you subject to any pending prosecutions? Yes/No
If the answer is YES, please give details of date(s), of offences(s) and sentences(s) passed or pending prosecutions, which are not spent on separate sheet.

Declaration of convictions

Safeguarding Children and Young People Form

1. Previous Surnames

2. Date of Birth3. Male/Female

4. Place of Birth (Town/county AND Country)

5. How long have you lived at your present address:

YearsMonths

6. Details of professional registration number e.g. CCETSW, DfEE, (or other professional body if appropriate)

State name of awarding body

7. Are you disqualified from working with children and young people, either through a court imposed disqualification order or through your inclusion on either the Department of health or Department for Education and Skills Lists of those banned from working with children or the PECS Register?

Yes / No

If yes, please give details

8. Are you subject to any pending disciplinary action, complaints or investigations in your current employment?

Yes / No

If yes, please give details

9. Has a previous employer ever taken disciplinary action against you?

Yes / No

If yes, please give details

10. Has a previous employer dismissed you?

Yes / No

If yes, please give details

11. The purpose of the following question is solely to assess whether candidates pose a risk to children. If, for any reason, you answer yes to this question, it will not automatically rule you out of the selection process. You will have the opportunity of fully discussing the circumstances with us at a face to face meeting.

Have you OR a member of your family living with you OR a person not related to you but living in your home, been the subject of a child protection investigation or enquiry either currently or in the past?

Yes / No

If yes, please give details

12. Can you confirm that the referees you have given on your application form are:

1 Your current or most recent employer

Yes / No

2 A person or persons able to give a professional opinion about your work/studies etc.

Yes / No

If no, please give details

DECLARATION:

I am committed to the aims and objectives of BIBIC in protecting and safeguarding children and young people from abuse. I understand that to knowingly give false information or to omit information will be considered as a breach of trust and could result in my dismissal at any time in the future. I understand that if I am subsequently convicted of any criminal offence, I must declare this to BIBIC. I declare that the information I have given on this form is correct.

Signed:

Date:

As an equal opportunity employer this organisation wishes to ensure that members of both sexes, married persons and members of all racial groups receive equal opportunities for selection for short listing for interview and appointment. A policy of monitoring job applications is maintained so that management can see whether satisfactory proportions of persons of both sexes, married persons and persons of different racial groups apply, and are given equal opportunity, for consideration for vacant jobs. As part of this monitoring policy, you are invited to give the following information:

Post applied for ...... …………………..

Name...... …………………..

Place of birth...... ………………….

Marital status...... ………………….

Age…………………………………………………Male□Female □

Ethnic origin (please indicate against the appropriate classification):

African (i.e. persons born in, or whose recent forebears were born in, Africa)□

Asian (i.e. persons born in, or whose recent forebears were born in, the Indian □

sub-continent)

Caribbean (i.e. persons born in, or whose recent forebears were born in, the □

Caribbean)

Black UK (i.e. persons born in England, Scotland, Wales or Northern □

Ireland whoserecent forebears were born in Africa, the Caribbean or the Indian

sub-continent)

White UK (i.e. English, Scottish, Welsh, Northern Irish)□

Other European (i.e. excluding the UK)□

Other (i.e. persons born in, or originating from countries not included in the above □

categories, and persons of mixed descent who choose not to classify themselves

elsewhere). This category is not intended to include West Indians who may identify

their origins as African. Equally, it should not include Europeans or Asians whose families

have settled in African countries. This category is intended to include Asians who were

born in the West Indies or whose recent forebears were born there.

This section of your application form will be separated immediately upon receipt of the completed form and its contents will not be communicated to those who are responsible for drawing up a short list of applicants for interview, or for interviewing them or selecting the successful applicant. However, if it is found that a proposed short list does not adequately reflect a balance on grounds of sex, marital status or race between the applicants when the information on these separate sections has been analysed, the addition of suitable candidates to the proposed short list (but not the removal of anyone already named on it) will be suggested before the invitations for interview are sent out. Your application will in no way be prejudiced if you decline to complete this section. It will be separated from the main application form whether or not you have completed it.

If you are selected for interview, you must provide the following original documents (a photocopy will be retained):

  • A passport showing that the holder is a British citizen, or has a right of abode in the United Kingdom.

or

  • A document showing that the holder is a national of a European Economic Area country or Switzerland. This must be a national passport or national identity card.

or

  • A residence permit issued by the Home Office to a national from a European Economic Area country or Switzerland.

or

  • A passport or other document issued by the Home Office which has an endorsement stating that the holder has a current right of residence in the United Kingdom as the family member of a national from a European Economic Area country or Switzerland who is resident in the United Kingdom.

or

  • A passport or other travel document endorsed to show that the holder can stay indefinitely in the United Kingdom, or has no limit on their stay.

or

  • A passport or other travel document endorsed to show that the holder can stay in the United Kingdom; and that this endorsement allows the holder to do the type of work you are offering if they do not have a work permit.

or

  • An Application Registration Card issued by the Home Office to an asylum seeker stating that the holder is permitted to take employment.

OR

A document giving the person’s permanent National Insurance Number and name. This could be a P45, P60, National Insurance card, or a letter from a Government agency.

Plus one of the following:

  • a full birth certificate issued in the United Kingdom , which includes the names of the holder’s parents;

or

  • a birth certificate issued by the Channel Islands, the Isle of Man or Ireland;

or

  • a certificate of registration or naturalisation stating that the holder is a British citizen;

or

  • a letter issued by the Home Office to the holder which indicates that the person named in it can stay indefinitely in the United Kingdom, or has no time limit on their stay;

or

  • an Immigration Status Document issued by the Home Office to the holder with an endorsement indication that the person named in it can stay indefinitely in the United Kingdom, or has no time limit on their stay;

or

  • a letter issued by the Home Office to the holder which indicates that the person named in it can stay in the United Kingdom, and this allows them to do the type or work you are offering;

or

  • an Immigration Status Document issued by the Home Office to the holder with an endorsement indicating that the person named in it can stay in the United Kingdom, and this allows them to do the type or work you are offering.

OR

A work permit or other approval to take employment that has been issued by Work Permits UK.

Plus one of the following:

  • a passport or other travel document endorsed to show that the holder is able to stay in the United Kingdom and can take the work permit employment in question;

or

  • a letter issued by the Home Office to the holder confirming that the person named in it is able to stay in the United Kingdom and can take the work permit employment in question.

PRE-EMPLOYMENT MEDICAL QUESTIONNAIRE

POSITION APPLIED FOR: ______

The following information will be treated in the strictest confidence.

PERSONAL (Please complete this section in BLOCK CAPITALS)

Full Name: / Name of Doctor:
Address: / Address of Doctor:
Private Tel. No.:

Please answer the following questions. If the answer is YES then please provide full details.

Have you at any time suffered from the following conditions:

ALLERGIES / GENITO-URINARY / NEUROLOGICAL
Allergies / YES/NO / Kidney stones / YES/NO / Dizzy spells / YES/NO
Asthma / YES/NO / Pain on urination / YES/NO / Epilepsy / YES/NO
Hay Fever / YES/NO / Sugar/albumin urine / YES/NO / Fainting attacks / YES/NO
Paralysis / YES/NO
CARDIOVASCULAR / MISCELLANEOUS / Severe headaches / YES/NO
Chest pain / YES/NO / Anaemia / YES/NO / RESPIRATORY
Heart disorder / YES/NO / Anxiety / YES/NO
High blood pressure / YES/NO / Blood disorder / YES/NO / Chronic cough / YES/NO
Palpitations / YES/NO / Cancer / YES/NO / Pleurisy / YES/NO
Rheumatic fever / YES/NO / Depression / YES/NO / Pneumonia / YES/NO
Diabetes / YES/NO / Sinusitis / YES/NO
DIGESTIVE SYSTEM / General Debility / YES/NO / Tuberculosis / YES/NO
Insomnia / YES/NO
Hernia / YES/NO / Skin disorder / YES/NO / SENSES
Jaundice / YES/NO
Peptic Ulcer / YES/NO / MUSCULOSKELETAL / Colour blindness / YES/NO
Rectal bleeding / YES/NO / Ear disorder / YES/NO
Arthritis / YES/NO / Eye disorder / YES/NO
Backache / YES/NO / Nose disorder / YES/NO
Back Injury / YES/NO / Throat disorder / YES/NO
Disc disorder / YES/NO
Gout / YES/NO
Joint/Tendon disorder / YES/NO
Rheumatism / YES/NO

Do you have a disability? ……………………………………………………………………………..

Are you registered as disabled? ………………………………………………………………………

(This information is required so that all disabled applicants who meet the minimum criteria are offered an interview)

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C:\Documents and Settings\Hazel\Local Settings\Temporary Internet Files\OLK4F5\BIBICApplicationForm.doc