We are committed to a fair selection process, and our decision to shortlist you will be based on the information you provide in Part 1 of this application form only. It is important that you give as much information as possible. If there is not enough space on the form, please continue on a separate sheet of paper and attach it securely to this form. We will not consider your CV unless the job advertisement asked you to provide it.

Disability Applicants with disabilities will be invited for interview if the essential job criteria are met.

Part 1

POSITION (applied for): / Job Ref No: / Candidate No:
SURNAME (block letters) Mr/Mrs/Miss/Ms
FORENAME(S) (block letters)
ADDRESS (if this is a temporary address, please also give your usual home address)
POSTCODE:
TELEPHONE No: Mobile / Home:
Email: / Work:
SIGNATURE: / DATE:
I declare that the information set out in this application form is true in all respects and that false information may render me liable for dismissal if I am appointed.
Employment History: Please list all appointments, beginning with your most recent, going back to the date when you left full-time education - ensuring there are NO GAPS in your employment history.
Name and address
Of Employer / Appointment
Held / Dates
From:
MM/YYY / Dates
To:
MM/YY / Reason for
Leaving
CURRENT SALARY
Duties and Responsibilities throughout your Employment which are relevant to this
application. (continue on a separate sheet if necessary)

Education Details: Please list, beginning with the most recent school/college etc

Name and address

Of school/college etc / Dates
From:
MM/YYY / Dates
From:

MM/YYY

/

Subjects

studied / Qualifications/
Grade /

Date

of
Attainment
Referees: Give names, designations and addresses of TWO people to whom reference may be made. One should be your present (or most recent) employer.
NB. It is the policy of Reach-Out Care to seek references prior to interview. If you have any objections to references being sought at this stage, please indicate.
References to be sought prior to interview Yes No
An Appointment will only be confirmed subject to satisfactory references.
Please supply telephone numbers for both reference.
1. / 2.
Tel: / Tel:
Email: / Email:
Additional Information:

Do you hold a full driving licence? Yes No

Do you have unrestricted use of a car? Yes No
Specific Requirements
If you have any specific requirements to assist you with an interview please detail them and we will make the necessary arrangements.
Eligibility to work in the Uk

Are you eligible to work in the UK? Yes No
If we decide to offer you the job, before you start work we will need to see proof that you are eligible to work in the UK, (if you do not have a National Insurance number, we will ask you for other evidence.)
We have a no-smoking policy.


PART 2

Position: / Job Ref No: / Candidate No:
We believe in equal opportunities and try to treat everyone who applies for a job fairly.
In working towards this, we ask you to complete the questions below.
We will keep the information you give in Parts 2 and 3 of this form confidential. We will not consider it during the selection process, and we will detach these pages before we shortlist applicants.
ABOUT YOU:
SURNAME (block letters) Mr/Mrs/Miss/Ms
FORENAME(S) (block letters)
ADDRESS (if this is a temporary address, please also give your usual home address):
POSTCODE:
TELEPHONE No: / CAN WE CONTACT YOU AT WORK IF NECESSARY?
Home :
Yes No
Mobil:
Work
Email:
Do you require any special arrangements for interview Yes No
If yes please give details:

The Rehabilitation of Offenders Act 1974:

This enables criminal convictions to become 'spent' or ignored after a 'rehabilitation period'. A rehabilitation period is a set length of time from the date of conviction. After this period, with certain exceptions, an ex-offender is not normally obliged to mention the conviction when applying for a job or obtaining insurance, or when involved in criminal or civil proceedings. Cautions, reprimands and final warnings are considered 'spent' immediately they are given. Some jobs are exempted from this Act. If this post requires an Enhanced or Standard Disclosure (refer to advert and job description) then you should provide details of All convictions, cautions, reprimands and final warnings. Where the post is subject to an Enhanced Disclosure, other relevant non-conviction information, such as police enquiries and pending prosecutions should also be declared. Relevant criminal convictions and other associated information will be discussed at the interview to assess job related risk.
Declarations:
Have you any spent convictions, cautions, reprimands and final warnings? Yes No
Have you any unspent convictions, cautions, reprimands and final warnings? Yes No
Are you waiting for a court case or is any other action currently being taken against you?
Yes No
If you answered Yes any of the above questions, and the job you are applying for needs an Enhanced or Standard CRB disclosure check, please give full details on the separate sheet titled ‘Rehabilitation of Offenders Act 1974’. Please put this sheet in a sealed envelope and attach it to your application form.

Have you ever been dismissed from a job because of misconduct, or resigned while disciplinary action has been taken against you?

Yes No
I can confirm that I am not disqualified from working with children or subject to sanctions imposed by a regulatory body.
Yes No
In accordance with DHSS Circulars LAC (93) 17, LAC (91) 4 and DFE circular 9/ 93 Reach-Out Care can and will carry out an Enhanced or Standard CRB check as to the existence and content of a criminal record of persons appointed to posts giving substantial opportunity for access to children. Any information will be treated in the strictest confidence and will be considered only where it is felt to be relevant to a particular job or situation. Your permission will be sought to carry out the CRB check following an offer of appointment but you should note that refusal to give permission could prevent confirmation of your appointment.

Please sign this section after you have filled in all parts of the form.

·  I authorise you to get references to support this application and that previous employers may be contacted for information. I agree that you will have no liability caused by giving and receiving information.
·  I understand the appointment, if offered, is subject to satisfactory pre-employment checks and subject to the information provided on the application form or any other document being correct.
·  Any false or misleading information provided on this form may result in any employment being terminated.

Signed: ……………………………………………. Date: ………………..

Data Protection:

We will keep all the information you give confidential in line with the Data Protection Act 1998, and any relevant European directives.

By signing and returning this application form you are giving us permission to use and keep the information you and your referees give us relating to your application for future employment. This information may include details about your health, your racial or ethnic origin and any criminal record. We will keep the information on computerised systems for monitoring purposes.

PART 3

Job Reference: / Candidate No:
Equal Opportunities Monitoring Form: Confidential
Reach-Out Care operates a policy of equal opportunities and wishes to ensure that all applicants are considered solely on their merits. Therefore, we need to be able to check that decisions are not influenced by unfair or unlawful discrimination. To help us to do this we should be grateful if you would complete this short questionnaire. Your answers will be treated in the utmost confidence and will only be used for statistical purposes.
Ethnic Origin: How would you describe your cultural or ethnic origin?
N.B. ethnic origin is not a matter of nationality, right of abode in the UK, or your place of birth.
Tick one box only

White Indian

Irish Pakistani
Black
African Bangladeshi
Black
Caribbean Chinese
Other
(please specify)

Sex: Female Male

Marital Status: Single Married

Date of Birth:
Sexual Orientation: Gay Lesbian Heterosexual

Religion:
Do you consider yourself to be a person with a disability as described by the Disability Discrimination Act 1995?
( i.e. Do you consider yourself to be someone who has a physical or mental impairment which has a substantial or long term adverse effect on your ability to carry out normal day to day activities?)

Yes No

Please state where you saw the advertisement for this post.

‘Reach Out Care is committed to the safeguarding and promotion of the welfare of children and expects all staff and volunteers to share this commitment.’