RESTRICTED WHEN COMPLETE

Office of the Police & Crime Commissioner (OPCC)

Application Form

Candidate Name:
Application for : Independent Member of the Audit and Ethics Committee
Closing Date:

When completed, this form should be returned to

Alyson Holmes, Head of Governance
Police & Crime Commissioner’s Office
PO Box 3167
Stafford
ST16 9JZ
or email

by no later than 6 December 2013

Please complete this form fully in black ink or typescript, which should be no smaller than 12 pitch. CV’s are not acceptable; please do not enclose with this form.

1. Personal Details
Surname:

Forename(s):

Preferred Title (e.g. Mr, Mrs, Ms, Dr):

Address:



Postcode:

Telephone: (home)

(work)

(mobile)

Email address:

National Insurance Number:

Disability Discrimination Act 1995 (as amended)

This Act widened the definition of disability and made it unlawful for employers to discriminate against people with a disability in all areas of employment, including recruitment.
The Disability Discrimination Act (DDA) defines a person as having a disability if they have a physical or mental impairment, which has a substantial and long term effect (ie has lasted or is expected to last at least 12 months) and has an adverse effect on the person’s ability to carry out normal day to day activities.

Interview Guarantee Scheme

The Office of the Police and Crime Commissioner (OPCC) is committed to the employment of anyone with a disability.
We operate a guaranteed interview scheme for anyone with a disability as defined in the Disability Discrimination Act 1995 (as amended).
If you consider yourself to be a disabled applicant and can demonstrate on your application form that you meet the criteria for this role you will be invited to participate in the next stage of the selection process.
Declaration:
I consider myself to have a disability as defined above and want to apply under the guaranteed interview scheme.
Yes
No

Reasonable adjustments or arrangements at interview

If you have a disability, are there any arrangements we can make for you if you are called for assessment/interview?

Yes
No
If Yes please outline your requirements:

2. Personal History

What is your current or previous occupation, if any?
Please give details of part-time and full-time employment as well as any voluntary work, career breaks, or any work you do or have done in the local community over the last ten years (most recent first please)
Employer/Appointing Body Name and Address:

Position Held:
Nature of responsibility:

Employer/Appointing Body Name and Address:

Position Held:
Nature of responsibility:
Employer/Appointing Body Name and Address:

Position Held:
Nature of responsibility:

3. Relevant Skills and Experience

Please give details of any previous experience in financial management, corporate governance, human resources, legal affairs in either the public, private or voluntary sectors or other relevant experience of scrutiny and challenge.

Education and Qualifications

Please list any academic, professional and/or vocational qualifications.

School/College/University Attended / Qualification / Grade

Relevant Training

Please give details of any training relevant to this role.

Course Title / Organising Body / Course Duration

4. Why do you want to be a member on the Audit and Ethics Committee

lease
Please say what qualities you would bring to the role if you were successful in your
Applic application, for example analytical ability, ability to scrutinise and challenge.

5. Vetting

The information requested below is required to complete vetting clearance.

Nationality
What is your nationality?

If a Commonwealth citizen or a foreign national, is your stay in the UK free of restrictions?
Yes No
If a Commonwealth citizen or a foreign national, you must include a copy of your passport which shows that your stay in the UK is free of restrictions.
Photocopy of passport enclosed?Yes No
Convictions and cautions (it is important you read the application guidance notes before you complete this section).
You must declare all convictions for any past offences, formal cautions by the police (including cautions as a juvenile, ie under 18 years) and any bind-overs imposed by any court. You should include traffic convictions such as speeding, drink-drive offences, fixed penalties for motoring or disorder offences and any appearances before a court martial.
You must declare any charge or summons currently outstanding against you.
You must include spent convictions under the Rehabilitation of Offenders Act 1974 (by virtue of the provisions of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975) or any involvement with civil, military or transport police.
Date
(most recent first) / Offence/
Alleged Offence / Result
(if known) / Court/
Police Station
Have you ever been involved in a criminal investigation (whether or not this led to any prosecution) or been associated with criminals?
Yes No
If yes, please give details below:
Have you ever been the subject of a civil order or child contact order with imposed restrictions under the Children’s Act 1989?
Yes No
If yes, please give details below:
About your family
Please tell us about your family (wherever they live), and any other adults living at your address. Continue on a separate sheet if necessary and attach to this page. Please complete all sections or your application will be delayed.
Relationship to you
(*delete as appropriate) / Full name (include previous surnames and name at birth, if different) / Full address (including postcode, if known, and dates of occupation where known).
Yourself
Date & place of birth / //
Your spouse or partner
Date & place of birth / //
Your father
Date & place of birth / //
Your stepfather or mother’s
partner
Date & place of birth / //
Your mother
Date & place of birth / //
Your stepmother or father’s
partner
Date & place of birth / //
Your brother or sister
(*full/half/step etc)
Date & place of birth / //
Your brother or sister
(*full/half/step etc)
Date & place of birth / //
Your brother or sister
(*full/half/step etc)
Date & place of birth / //
Your brother or sister
(*full/half/step etc)
Date & place of birth / //
Your spouse’s/partner’s mother/stepmother etc
Date & place of birth / //
Your spouse’s/partner’s father/stepfather etc
Date & place of birth / //
Relationship to you (*delete as appropriate) / Full name (include previous surnames and name at birth, if different) / Full address (including postcode, if known, and dates of occupation where known).
Your child/child of partner (only state if aged 10+)
Date & place of birth / //
Your child/child of partner (only state if aged 10+)
Date & place of birth / //
Your child/child of partner (only state if aged 10+)
Date & place of birth / //
Previous addresses
Please give all addresses at which you have lived over the last five years. Start with the mostrecent. Do not include your current address.
Full address (include postcode, if known) / Approximate dates from (month/year) to (month/year)

6. Monitoring Information

The OPCC is an equal opportunity employer and is determined to ensure that:
  • The workforce reflects the diverse society which it serves and that the working environment is free from any forms of harassment, intimidation, bullying or victimisation.
  • No applicant or employee is treated more or less favourably on the grounds of gender, sexual orientation, age, disability, marital status, race, colour, nationality, ethnic or national origins, creed or religion.
To implement and monitor the effectiveness of the equal opportunities policy, the following information is required. The information you give will not affect your application in any way.
Please choose one option from each of the sections listed below and then place a tick in the appropriate box.

Your gender

Male
Female

Your age

16 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65+

Your ethnic group

A White
British
Irish
Eastern European
Any other White background, please write in
B Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background, please write in
C Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background, please write in
D Black or Black British
Caribbean
African
Any other Black background, please write in
E Chinese or other ethnic group

Your religious belief/faith

Buddhist
Christian (state denomination if you wish)
Hindu
Humanist
Jewish
Muslim
Sikh
None
Other (please state)

Prefer not to say

Your sexual orientation

Bisexual
Gay/Lesbian
Heterosexual
Prefer not to say

Your Disability

Do you consider yourself to have a disability according to the terms given in the Disability Discrimination Act?

Yes
No
If yes, please provide details:

How did you find out about this role?

Please specify the source or publication:

Data Protection Act

The Data Protection Act 1998 places responsibilities on us to process personal data that we hold in a fair and proper way. The Act came into force on 1 March 2000 and regulates the use of personal data, including any data you supply on this application form.

The OPCC may contact other organisations (such as the Criminal Records Bureau, previous employer(s), educational establishments, etc) to check that factual information has been given on the application form. The information will be stored securely, both manually and electronically and destroyed after 12 months if your application is unsuccessful.

The Office is under a duty to protect funds it administers, and to this end may use the information you have provided as part of the recruitment process for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes.As part of this ongoing responsibility Staffordshire Police, on behalf of the OPCC, participates in the Audit Commission National Fraud initiative every two years. Key payroll and other data is used in a matching exercise to identify frauds, data errors etc.

7. References

Please give details of two people, not related to you, who have agreed to be contacted by the OPCC about your application. It would be helpful if one referee was familiar with your previous experience in financial management etc.
Name: Name:
Address: Address:
Tel No: Tel No:
Email: Email:
Position: Position:

8. Declaration

I declare that all the statements I have made in this application are true to the best of my knowledge and belief and that no relevant information has been withheld.
I understand that:
  • I must inform the OPCC without delay of any change in my circumstances.
  • Vettingenquiries will be made against myself and my family members and I have informed them of this.
  • Any offer will be subject to satisfactory references and vetting.
  • I need to speak to my employer about the time commitment involved should my application be successful (if applicable).
  • The PCC retains the right to reject any application without giving reasons.
  • The information I have provided may be held on manual filing and computer systems as part of the recruitment process.
SignatureDate

9. Checklist

  • Ensure that you have answered all the questions, marking them not applicable (N/A) where appropriate.
  • Failure to provide accurate and complete information may result in your application being delayed or rejected.
  • Remember to take a photocopy of your completed application form.
  • Have you included a telephone number at which you can be contacted?
  • If you are a Commonwealth citizen or a foreign national, have you included
a photocopy of your passport with evidence that your stay here is not subjectto restrictions?
  • Have you signed and dated the above declaration?

RESTRICTED WHEN COMPLETE