Cleveland Youth Association

Richard Crosthwaite Centre, Sotherby Road, Middlesbrough, TS3 8BT

Tel No: (01642) 282222 Fax No: (01642 282223) Email:

(CYA is an equal opportunities employer. We aim to recruit a diverse workforce which reflects the make up of the local community. We are committed to promoting diversity principles.)

APPLICATION FORM FOR THE POSITION OF:

CONFIDENTIAL

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Please complete ALL sections of this form.

PERSONAL

Surname: Forename(s):

Address:Postcode:

Telephone (Private): Telephone (Business):

Mobile telephone: Email:

Marital Status:

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Please be aware that if your application is successful, you will be asked to either complete a Disclosure and Barring Service (DBS) Application Form or notify us of your DBS Update Service registration number and produce your last DBS certificate. A criminal record will not necessarily prevent you being employed by Shape and will be treated in strict confidence.

NOTE This organisation is committed to safeguarding and promoting the welfare of young people and expects all staff and volunteers to share this commitment.

Do you have any convictions, cautions, reprimands or final warnings that are not “protected” by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198? (http://www.legislation.gov.uk/uksi/2013/1198/pdfs/uksi_20131198_en.pdf)

YES/NO (delete as necessary)

Anyone who wilfully suppresses any relevant information will incur the risk of losing the appointment.

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TRANSPORT

Do you have a current driving licence? YES/NO (delete as necessary)

How long have you held a licence?

Do you have any endorsements? YES/NO (delete as necessary)

If yes, please give details:

EDUCATION

Secondary Schools / From / To / Part/Full / Qualifications Gained
College/University
Further Education/Formal Training
Professional membership and qualifications and dates obtained:
What specific skills or experience do you feel especially suit you for the job for which you are applying? Please include any experience as a volunteer or paid worker with young people:

OTHER INFORMATION

Please give brief details of spare-time activities and interests:

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EMPLOYMENT HISTORY (Start with your present/last employer and work backwards in date order. – continue on to next page if necessary)

DATES / EMPLOYER / Number
of Employees / Position Held / Main duties
and Responsibilities / Salary on Leaving / Reason for Leaving
From / To / Name & Full Address / Type of Business
DATES / EMPLOYER / Number
of Employees / Position Held / Main duties
and Responsibilities / Salary on Leaving / Reason for Leaving
From / To / Name & Full Address / Type of Business

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REFERENCES

Please give details of two people who are willing to give references on your behalf. One of them should be your present or latest employer.

Please state whether you have worked or volunteered with young people before: YES/NO

(delete as necessary)

If you have answered Yes to the above question, one of your referees should be from an organisation that has knowledge of your work or volunteering with young people.

If one of your references is a personal reference please ensure you are well known to the person but not in any way related

First Reference (Employer)

Name: Position:

Address:

Postcode: Telephone Number:

Second Reference

Name: Position:

Address:

Postcode: Telephone Number:

Please state whether reference may be made NOW to your present or latest employer YES/NO

(delete as necessary)

Please note that if you should be successful at interview, any offer of employment would be on a provisional basis pending an approach to your latest employer.

When would you be able to take up this appointment?

How did you learn of this vacancy?

I certify that the statements I have made in this application are true. I authorise SHAPE to investigate the accuracy and completeness of this information. In the event of my employment, I understand that any false or misleading statements made by me, in this application, will be sufficient grounds for immediate dismissal from employment.

I believe there is no reason why I would be unsuitable to work with young people.

SIGNATURE: DATE:

(If you complete this form online and are invited for interview, you will be required to sign the form at interview.)

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