APPLICATION FOR EMPLOYMENT – PERSONAL INFORMATION

Please complete fully and return to: with your CV and supporting letter

POSITION APPLIED FOR: /

Chief Executive

CONTRACT TYPE: /

Permanent

PERSONAL DETAILS

Title: / Mr  / Mrs  / Miss  / Ms  / Other (please specify):
First name(s):
Present surname:
Home address:
Postcode:
Home telephone (including STD code):
Mobile phone:
Home e-mail address:

REFERENCES

Please give details of tworelevant employmentreferences that know you well enough to comment on your suitability for the post. One of these must be your current or most recent employer if currently unemployed or self-employed.
  1. Name of Referee:

Job Title:
Company Name & Address:
Postcode:
Telephone (including STD code):
Email address:
  1. Name of Referee:

Job Title:
Company Name & Address:
Postcode:
Telephone (including STD code):
Email address:

ELIGIBILITY TO WORK IN THE UK

Are you eligible to live and work in the UK? / Yes
No
Please confirm you would be able to provide a ‘specified document’ (e.g. a P60, UK or Eire birth certificate, passport) confirming this? / Yes
No

DECLARATIONS

Declarations of interests

Are you a tenant, former tenant, a relative of a tenant or do you have any financial interests with Connect Housing? / Yes
No
Are you related to any member of Connect Housing’s Board of Management or employees? / Yes
No
Have you undertaken paid employment, in any capacity, for Connect Housing within the last 12 months? / Yes
No
Do you have any other employment (including part-time or night work) that you intend to continue? / Yes
No
Do you have any holiday commitments in the next 12 months? / Yes
No
If you have answered YES to any of the above questions, please tick the box and provide details on a separate sheet.
Do you have a current full clean driving licence? If NO, please provide details on a separate sheet. / Yes
No / Do you have a car available for work use? / Yes
No
Have you ever been dismissed from employment? If YES, please give details on a separate sheet / Yes
No

Criminal Records

Criminal records are taken in account for recruitment purposes only when the conviction is relevant. Unless the nature of the work demands it, you will not be asked to disclose convictions which are ‘spent’ under the Rehabilitation of Offenders Act 1974. Having an ‘unspent’ conviction will not necessarily bar you from employment. This will depend on the circumstances and background to your offence(s). To meet requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974, all applicants who are offered employment may be subject to a criminal record check from the Criminal Records Bureau before the appointment is confirmed. This would include details of cautions, reprimands or final warnings, as well as convictions. Failure to declare convictions, if found out, would result in disciplinary action being taken against you and likely dismissal from your post.
Have you ever been convicted of a criminal offence? (NB. The Rehabilitation of Offenders Act 1974) / Yes
No
If you have answered YES to the above question, please tick the box and provide details on a separate sheet.
Please read the following carefully and then sign and date below to indicate your agreement with the declaration that applies to all information provided by you in this application form.
I confirm that the information contained in this application is correct and I consent to it being processed[1] for the purposes of recruitment. I understand that the information submitted in this application would form a part of my contract of employment with Connect Housing. If it is subsequently discovered that I have wilfully or negligently given false information or withheld information, I would be liable to immediate dismissal. I understand that canvassing directly or indirectly may lead to disqualification.
Applicant Signature: / Date: / //

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H:\Documents\Forms\Connect Forms\Employment application form (standard) NEW 2010.doc

A charitable housing association

APPLICATION FOR EMPLOYMENT – SUPPORTING INFORMATION

MONITORING INFORMATION

Connect Housing aims to promote equality of opportunity for all so we can maintain the right mix of talent, skills and potential for the organisation. We welcome applications from a diverse range of candidates. In order to monitor our equality and diversity policies and for that reason only, we ask you to give the details requested. This information will remain confidential and will be detached from the application form and not used as part of the selection process. The information will be used for statistical purposes only. Only information directly relating to ensuring equality of opportunity for disabled people will be made available to the selection panel.
ETHNIC ORIGIN
Please indicate to which ethnic group you belong. Ethnic origin is not about nationality, place of birth or citizenship; it concerns colour and broad ethnic group. Tick one box from these options.
 / Asian/Asian British: Bangladeshi /  / Mixed: White/Asian
 / Asian/Asian British: Indian /  / Mixed: White/Black African
 / Asian/Asian British: Pakistani /  / Mixed: White/Black Caribbean
 / Asian/Asian British: Other /  / Mixed: Other
 / Black/Black British: African /  / Other
 / Black/Black British: Caribbean /  / White: British
 / Black/Black British: Other /  / White: Irish
 / Chinese /  / White: Other
If you have ticked any of the “Other” boxes above, please give details here:
AGE / Date of Birth: / //
GENDER / Male: /  / Female: /  / Prefer not to say: / 
RELIGIOUS BELIEF/FAITH (PLEASE TICK AS APPROPRIATE)
Atheism / Buddhism / Christianity / Hinduism / Islam (Muslims)
Jainism / Judaism (Jews) / Sikhism / None / Prefer not to say
SEXUAL ORIENTATION (PLEASE TICK AS APPROPRIATE)
Lesbian/Gay Woman / Gay Man / Bisexual / Heterosexual / Prefer not to say
Disability
To allow us to consider any reasonable adjustments to the recruitment process, please tick one or more of the following statements that are appropriate to you. Please give any further details in the space provided.
 / I do not have a disability
 / I have dyslexia/discalculia
 / I am blind/have a visual impairment *
 / I am deaf/have a hearing impairment
 / I am a wheelchair user/have mobility difficulties
 / I have an unseen disability, e.g. diabetes, epilepsy
 / I have a disability not listed above
* if this box is ticked, please name the person who has completed this form (if not the applicant):
What, if any, arrangements, facilities or support would you require to enable you to attend the interview and/or carry out the duties and responsibilities?

The information you enter on this form will be used for monitoring only and in no way forms any part of the selection process. Please help us to ensure we provide a fair service to all and enclose this completed section with your application form.

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H:\Documents\Forms\Connect Forms\Employment application form (standard) NEW 2010.doc

A charitable housing association

[1] The Data Protection Act 1998 (DPA). The information you provide on this application form will be processed only for the purposes of recruitment by persons necessarily involved in the recruitment procedure. We may contact relevant third parties in order to verify certain information given in your application (E.G. REFERENCES). You have a right to have your application processed manually and to appeal against any negative outcome of automated processing. On completion of the recruitment procedure, information on you may be stored for a period of up to six months after which time it will be destroyed.