Mill Hill School

MILLHILLSCHOOL

Peasehill, Ripley, Derbyshire DE5 3JQ

Achieving Excellence Together

Acting Headteacher : Mrs Carey Ayres / Tel: (01773) 746334
Fax: (01773) 570685
E-mail:
Website:
JOB APPLICATION FORMAs an equal opportunities employer we welcome applications from all sectors of the communityAPPLICATION FOR THE POSITION OF: ______
PLEASE COMPLETE IN BLACK TO FACILITATE PHOTOCOPYING
You are requested to complete this form (using supplementary sheets if there is sufficient space for any entry). For guidance on completing this form, please look at the Guidance Notes.

ALL SECTIONS MUST BE COMPLETED

PERSONAL DETAILS

Surname/Family Name: / Preferred Title:
First Name(s): / Previous Surname
Home Address: / Present Address:
Post Code: / Post Code:
Telephone (Home): / Telephone (Work):
Telephone (Mobile): / Email:
Date of Birth:
CURRENT EMPLOYMENT (If you are not currently employed as a teacher please give details as appropriate).
Name of Establishment: / Employer:
Type of School: / Key Stage:
Post Held: / Date Appointed:
Pay Scale: / Total Annual Salary:
If your salary includes additional payments, what are they and what is the value? (eg TLR of £4,000)

PREVIOUS EMPLOYMENT DETAILS

Please list in chronological order, with precise dates if possible, as this information may be used to assess salary.

a)In Education (Supply teaching appointments need to be listed individually)

b)Any other employment

Employer and Establishment / Post and Grade / Type of School/Key Stage / From / To / Reason for leaving
Employer and Establishment / Post and Grade / Type of School/Key Stage / From / To / Reason for leaving

HIGHER EDUCATION

Establishment(s) / From / To / Full/Part-time / Qualification Awarded
Degree / Class / Division / Date of Award
Degree
Or Cert.Ed
PGCE / Key Stage
Other / Subject

SECONDARY SCHOOL EDUCATION

Establishment(s) / From / To

Examinations (for first teaching appointment in a Local Authority – maintained school in England or Wales please give details of ‘A’ levels and GCSEs, or equivalent i.e. Subject, Date, Results/Grade).

School / Date / Results/Grade

OTHER QUALIFICATIONS OBTAINED

Course and Organising Body / Date / Qualification

PERIODS NOT ACCOUNTED FOR IN PREVIOUS SECTIONS SINCE AGE 18 (Please give details)

From / To
Month / Year / Month / Year

LEISURE INTERESTS

Please state briefly what your main interests are, particularly where these are relevant to the work for which you are applying.

REFERENCES

Please give the names, addresses and status of two referees who may be approached now.

References from friends or relatives are not acceptable.

(If you are currently employed as a teacher, one referee must be your present Headteacher).

1) Name: / Status:
Address:
Telephone:
2) Name: / Status:
Address:
Telephone:

If you are known to the referees by another name (eg previous name) please inform them of your present name and advise that we may be in contact.

From what source did you learn of this vacancy?
Are you a relative or partner of any employee or governor of the school?
If yes, please give details ………………………………………………………….. / Yes/No
Has someone else completed this form on your behalf?
If yes, please provide the person’s name and an explanation. / Yes/No
I certify that the information given above and overleaf is correct to the best of my knowledge. I accept that if any of the enclosed information is found to be untrue or misleading after my appointment, I may be liable for dismissal without notice.
Signature:
Date:

If you are not currently employed in a maintained school in this authority you must supply additional information below:

ADDITIONAL INFORMATION (for salary and pension purposes)
This information is required only if you are not currently employed in a maintained school in this authority.
National Insurance No. / Teacher Reference No. (DCSF --/---
Date of Recognition* / Date of Registration with the GTC:
*If this would be your first teaching appointment in a Local Authority – MaintainedSchool in England and Wales, please attach a copy of your letter from the DCSF granting your Qualified Teacher Status.
PENSIONS
Are you currently in receipt of a pension from Teachers’ Pensions? / Yes/No
Have you elected OPT-OUT of the Teachers’ Superannuation Scheme? / Yes/No
If yes, please provide date
Have you elected to pay additional Superannuation Contributions through the Teachers’ Scheme? / Yes/No
If yes, please provide date
If yes, please indicate whether these are:
i) Widower’s Contributions / Yes/No %
ii) Purchase of Past Added Years / Yes/No %
iii) Additional Voluntary Contributions via Prudential Assurance Co / Yes/No %

Please attach a copy of the Teachers’ Pensions notification as appropriate.

In the interests of economy, receipt of this application may not be acknowledged unless specifically requested

(in which case please enclose SAE)

YOU NEED TO COMPLETE THE FOLLOWING PERSON SPECIFICATION FORM

MILLHILLSCHOOL

Peasehill, Ripley, Derbyshire DE5 3JQ

Achieving Excellence Together

Acting Headteacher : Mrs Carey Ayres / Tel: (01773) 746334
Fax: (01773) 570685
E-mail:
Website:
PERSON SPECIFICATION FORM

PLEASE COMPLETE IN BLACK TO FACILITATE PHOTOCOPYING

You are requested to complete this form (using supplementary sheets if there is insufficient space for any entry)

• It is essential that you complete and return this form

• This form is your chance to show us how well you can do this job

• Remember, just saying you can do it is not enough; we need an example

• You can use examples from work, school, college, hobbies

Example: Ability to prioritise workload
In my current job I plan my work on a daily basis but adjust it when an urgent query or problem arises, eg when another team member unexpectedly calls in sick. I always raise any urgent issues with my manager.
SKILLS AND ABILITIES
EXPERIENCE
KNOWLEDGE
Please note that if you are invited to interview, you will be asked about the boundaries between adults and children in a school.
Signed:
Date:

MILLHILLSCHOOL

Peasehill, Ripley, Derbyshire DE5 3JQ

Achieving Excellence Together

Acting Headteacher : Mrs Carey Ayres / Tel: (01773) 746334
Fax: (01773) 570685
E-mail:
Website:
REHABILITATION OF OFFENDERS ACT 1974

It is essential that, in making your application, you disclose whether you have been convicted of a criminal offence and, if so, for what offence. Because of the nature of the position for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitation of Offenders 1974 (Exceptions) Order 1975 and the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendments) Order 1986. The fact that conviction(s) have been reported against you will not necessarily debar you for consideration for this appointment.

The object of this notice is not, in any way, to reflect upon applicants’ integrity, but it is necessary to protect the Public and the Employers.

In accordance with the recommendations of the Home Office, successful candidates will be the subject of a request to Derbyshire Constabulary for a search by the Criminal Records Office, regardless of the answer given to the question concerning previous convictions.

Acceptance of an offer of appointment will be deemed to be acceptance that such an investigation may take place. Applicants are informed that providing false information is a disciplinary matter and may result in summary dismissal.

Have you ever been convicted of a criminal offence?YesNo

If yes, provide full details:

Signed:Date

MILLHILLSCHOOL

Peasehill, Ripley, Derbyshire DE5 3JQ

Achieving Excellence Together

Acting Headteacher : Mrs Carey Ayres / Tel: (01773) 746334
Fax: (01773) 570685
E-mail:
Website:

Equal Opportunities Monitoring

Disability /

Tick

A) Do you consider yourself disabled? / one / YES / NO
B) Do you feel that you meet the Disability Discrimination Act (DDA) definition of disability? (If you have a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day to day activities) / Tick one / YES / NO

Select only one option from A – E;

then tick one category within the option that indicates your cultural background

Ethnic origin
A)
White / tick one / B)
Mixed / tick one / C)
Asian or Asian British / tick one / D)
Black or Black British / tick one / E)
Chinese or other ethnic group / tick one
British / wb / White & Black Caribbean / mc / Indian / ai / Caribbean / bc / Chinese / oc
Irish / wi / White & Black African / mb / Pakistani / ap / African / ba / Any other / ot
Other White
Background / wo / White & Asian / ma / Bangladeshi / ab / Other Black
Other Mixed background / mo / Other Asian / background / bo
background / oa

Please tick one box only that identifies your Sexual Orientation * see guidance

Heterosexual / Lesbian / Gay / Bisexual / Prefer not to say / Other

Please tick one box only that identifies your Religion/Belief * see guidance

Buddhist / Christian (all denominations) / Hindu / Jewish / Muslim / Sikh / None / Other religion or belief / Prefer not to say

*Sexual Orientation, Religion and Belief - The School is collecting monitoring information on sexualorientation, religion and belief to ensure it becomes an Employer of Choice, an inclusive School which values diversity, is representative of the community it serves and meets the objectives of its Equality and Diversity Policy.

CONFIDENTIAL

Please note: This document is not used for the purposes of short listing candidates.

Mill Hill School, Peasehill, Ripley DE5 3JQ1