APPLICATION FORM

Please complete this form in BLACK ink or type to ensure that it is clear when photocopied. If you need additional space please use a piece of A4 paper with your name clearly marked at the top. In completing this form, please ensure that you answer all the points in the person specification.

Position applied for:

Reference No:

Closing date for applications:

PERSONAL DETAILS

Surname

First Names

Preferred Title

Address

Telephone Home Work

Mobile email

Please indicate if you would prefer us not to phone you at work. YES NO

If you were successful, how soon would you be able to start?

Please state where you saw or heard about the job

LANGUAGE SKILLS

Please state whether you have any language skills, including British Sign Language (please note this is for information only, and is not a requirement of the job unless it is on the person specification).


EDUCATION AND TRAINING

Please list any education and/or training, including short courses and workshops which you think are relevant to your application, starting with the most recent.

NATURE OF COURSE / QUALIFICATION OBTAINED / DATES

WORK EXPERIENCE

Please list, with dates, any experience, positions held or placements both paid or unpaid, starting with the most recent.

DATES / EMPLOYER / POST HELD / REASON FOR LEAVING /

SALARY

Please give your current or most recent annual salary: £

SUPPORTING STATEMENT

Please state why you are applying for this post and what skills, experience and knowledge you will bring to the work. Shortlisting will be done on the basis of the job description and person specification so it is important that you consider them both when answering and ensure that you have responded in detail, with examples where possible, to each point on the person specification. This form will allow you to continue on additional pages..


Authorisation to Work in the UK

In accordance with the Immigration, Asylum and Nationality Act 2006 we are required to check your eligibility to live and work in the UK.

Are you currently able to work legally within the UK for a minimum period of 12 months or for the maximum term of the contract if less than 12 months?

YES NO

Do you require a visa to work in the UK? YES NO

If yes, please confirm that on request you will be able provide this evidence.

YES NO

Rehabilitation of Offenders Act 1974 (Exceptions) (Amendments) Order 1986

All applicants are required to declare any criminal conviction(s) including bindovers and cautions which are ‘unspent’ and/or any pending prosecutions. Certain posts within the Council are exempted under the Rehabilitation of Offenders Act 1974. If the post for which you are applying is an ‘exempt’ post you must declare all convictions including ‘spent’ convictions and, if shortlisted, you will be asked to complete a more detailed form so that a criminal records check can be made.

Do you have any criminal convictions (including ‘spent’ and ‘unspent’), cautions/bindovers or prosecutions pending?

YES NO

If you have answered yes please ensure any information is placed in the space provided below or in a sealed envelope which clearly states your name along with the job title and reference number and returned with your application form.

CRIMINAL RECORDS BUREAU CHECK

The successful applicant will be required to undertake a Criminal Records Bureau check. Please state whether you have had one of these in the last three years, and if so, please give the date.


REFERENCES

Please give two references, including a present or previous employer if possible. References will not be taken up until after an offer of an appointment is made.

Name Name

Address Address

Telephone Telephone

In what capacity do you know them? In what capacity do you know them?

DECLARATION

I declare that the information given in this application is to the best of my knowledge true and accurate. I know of no reason through conduct and/or association which would prevent me from providing a high quality service to women and their children experiencing domestic abuse. I understand that if the information provided is false or misleading in any way, it will result in my application not being pursued, or if appointed, may lead to disciplinary action and dismissal.

SIGNATURE DATE

I consent for my application to be held on file for future vacancies if I am shortlisted

YES NO

PLEASE RETURN COMPLETED APPLICATION TO:

Rise

PO Box 889

Brighton

BN2 1GH

OR

NOTE: If you have not received a response within two weeks of the closing date, please assume you have not been successful. We regret we will be unable to write to all unsuccessful applicants.

Thank you for your interest in Rise.

EQUAL OPPORTUNITIES MONITORING

Please could you mark the appropriate boxes below. This page will be removed before shortlisting. We always work towards anti-discriminatory practice and this information will be used for monitoring purposes only.

This information is held CONFIDENTIAL and ANONYMOUS. Thank you for your assistance.

GENDER Are you: female male

ETHNIC GROUP Please mark the appropriate boxes from (a), (b) and (c) to indicate your colour, cultural or ethnic background and religion.

(a) [B] Black………………

[W] White……………… [M] Mixed………………

[O] Other……………….

(b) 1. African ……………. (c) 1. Christian……………

2.  Caribbean ….. ……. 2. Buddhist……………

3.  Indian ..….….. ……. 3. Hindu………………

4.  Pakistani .…………. 4. Muslim………….….

5.  Bangladeshi .. ……. 5. Sikh………….. ……

6.  Chinese ……. ……. 6. Jewish……………..

7.  Irish …………. ……. 7. None……………….

8.  European/UK ……. 8. Other………… ……

9.  Other ………………

Please state Please state

AGE Please mark to indicate your age group

1. Under 18 …………… 4. Aged 40-49 ………

2. Aged 18-29 ………… 5. Aged 50-59 ………

3. Aged 30-39 .……….. 6. Aged 60 + ……….

SEXUAL IDENTITY Please mark to indicate how you define your sexual identity

1. Lesbian ……………. 4. Heterosexual ……...

2. Gay … ……………... 5. Bisexual ……………

3. Other ……………….

Please state

DISABILITY Do you have an impairment? YES NO

If YES, is it: Visible ……

Invisible…..

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