CONFIDENTIAL APPLICATION FORM

Please complete in black ink and block capitals
Return to : Lois Dale, East Midlands Councils, First Floor Office, South Annexe, Pera Business
Park,NottinghamRoad, Melton Mowbray, Leicestershire LE13 0PB or via e-mail at
.
CV’s will only be accepted in support of your application form
Post Applied for: Programme Manager
Closing Date: 27 October 2017
PERSONAL DETAILS
Title: Forename(s): Surname:
National Insurance Number:
Address:
Postcode: / Tel No (Home):
Tel No (Work):
May we contact you at work? Yes/No
(delete as appropriate)
Mobile:
Email:
Do you hold a current driving licence? / Yes/No (delete as appropriate)
Do you have a vehicle available for use at work? / Yes/No (delete as appropriate)
EDUCATION AND QUALIFICATIONS
Indicate School/College attended and qualifications obtained: (CSE, GCSE, "O", "A", Degree, Post Graduate etc.)
Name of School/College/University / Date From / Date To / Subject/Qualification and Grade
TRAINING AND DEVELOPMENT
Indicate attendance at Seminars, Lectures, Workshops or Short Courses whether or not leading to a recognised Qualification.
Training Provider/ Organising body / Name of Training Course/Event / Duration
From / To
Please give details of any professional body/association of which you are a member please state type of membership and date achieved:
PRESENT EMPLOYMENT
Employer (name and address) / Position / Salary/Grade
(include any benefits) / Date From / Notice Period
Duties:
Reason for leaving or wishing to leave:
PREVIOUS EMPLOYMENT
Please include any previous work experience whether paid, unpaid or voluntary starting with the most recent. Please include any breaks in your career (e.g. travelling, family, studying, unemployed). Please continue on a separate sheet if necessary.
Employer / Position and Duties / Date From / Date To / Reason for Leaving / Final Salary
SUPPORTING STATEMENT
Please use this space to give any further or more detailed information in support of your application. (Attach additional sheets if required)
ADDITIONAL INFORMATION
How many sick days have you taken in the last 2 years?
Availability for Interview: (Please give details of any dates within November when you would NOT be available for interview)
Arrangements for interview: (If you have a disability and there are any arrangements which can be made for you if you are called for interview please advise below:)
REFERENCES
Please give details of 2 people who can provide employment references. 1 should be your present/ most recent employer. If known to your employer under another name, please indicate.
Name:
Position:
Organisation:
Address:
Telephone:
Relationship to applicant:
May contact be made prior to interview?
Yes/No (please delete as appropriate) / Name:
Position:
Organisation:
Address:
Telephone:
Relationship to applicant:
May contact be made prior to interview?
Yes/No (please delete as appropriate)
DECLARATION
I declare that I am/am not (delete as appropriate) related to any Member or Officer of East Midlands Councils. Canvassing Members of any Local Authority either directly or indirectly will disqualify an application.

If related to a Member/Officer, please indicate name and relationship:

I certify that to the best of my knowledge, all of the information I have given is correct. I understand that deliberately giving false, misleading or incomplete answers would disqualify me from consideration or, in the event of my appointment, make me liable to dismissal without notice.
SIGNED: DATE:
Data Protection Act 1998
All personal information supplied will be used solely for personnel administration procedures for recruitment purposes, no information will be passed on to others or used for purposes other than those stated on this form.

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