Perm Placement Declaration Form – Please Return

1.Personal Details
Surname: / Forename (s):
Title: / Date of birth:
Teacher reference no.
2A. Criminal Record Checks
REHABILITATION OF OFFENDERS ACT 1974 (EXCEPTIONS) ORDER 1975 – UK
Spent convictions need not be declared under the Rehabilitation of Offenders Act 1974. However, where individuals are working with children and or adults in receipt of regulated services, the provisions of section 4(2) of the Rehabilitation of Offenders Act 1974 do not apply. Consequently, you are NOT entitled to withhold information about convictions, cautions, reprimands and warnings which are considered spent under the Act other than certain old and minor cautions and convictions that are classed as “protected” under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013. The information you give will be treated in confidence and only take into account where the offence is relevant to the post for which you are applying. Failure to declare any information may require us to exclude you from our register if the offence is not declared but later comes to light. Randstad complies fully with the DBS Code of Practice and undertakes to treat all applicants for positions fairly. It undertakes not to discriminate unfairly against any subject of a disclosure on the basis of conviction or other information revealed.
Other than in respect of protected cautions or protected convictions, have you ever been convicted of a criminal offence, received any cautions/reprimands/warnings or do you have knowledge of any pending prosecutions in respect of alleged criminal offences excluding road traffic offences not involving injury to a third party or a sentence of imprisonment?
Please circle as appropriate: / YES / NO
If Yes, please provide details in section 2B – please use separate sheet if required
2B.Details of any convictions, caution or Bind-over:-
3. Disqualification from Working with Children
Please tick if accurate. I can confirm that: / 
I am not a parent of a child who at anytime has been made the subject of a Education order and no other order has been made with the purpose of removing a child from my Education , other than a custody or residence order in favour of the child’s other parent.
I have not been concerned with the management of, or had any financial interest in a voluntary or registered home which has been removed from a register.
I have not been refused registration of a voluntary or registered home in relation to any application made.
I have not been prohibited from being a foster parent or refused registration to be a child minder or provider of day Education or had such registration cancelled
I have not been convicted of an offence listed in the Schedule to the Regulations
If you are unable to tick any of the statements above, please give the circumstances below. (Feel free to expand on an
additional sheet if required)
4. Professional references
These will be taken from your employment history supplied on your CV, your telephone interview with Randstad Education or the school application form. Prior to an interview with a Randstad Education client we will always request a reference from your current employer, unless you have stated otherwise. We reserve the right to contact all previous employers.
I can confirm that I am aware that Randstad Educationwill request professional references from my current employer prior to interview with a Randstad client.
I can confirm that I am aware that Randstad Education will request professional references from my previous employer.
I am giving my consent for the release of this information to Randstad Education and to then forward and discuss the information, where required, to the appropriate client contact.
5. Declaration
I have filled in this declaration form to the best of my knowledge and understanding, and I have omitted no relevant details. I accept that if any false statements are made, this may result in the termination of any successful applications and / or the processing of any applications.
•I hereby give my consent for all my details to be stored on computer
•I confirm that I have (re-) registered with Randstad Education through my own choice
•I confirm I am happy for Randstad Education to offer me work seeking services
•I confirm that, should any of my personal details change, I will inform Randstad Education immediately
•I accept that Randstad Education have no obligation to find me employment, nor do I have any obligation to accept any offers
•I confirm that I have read and understood the information in this application form
•I confirm that I am not an employee of Randstad Education , nor that I have any intention of becoming an employee of Randstad
Education
Signed: / Date:
Randstad Education will hold and process your data for recruitment purposes only and, from time to time, may contact you for market research purposes and / or to make further offers to you. Your data may also be used for audit purposes by third parties, and be passed to other companies within the Randstad Holdings nv group or their legal advisers. If you would prefer not to be contacted in any manner, including email, once you are no longer seeking work, or do not give your consent for your data to be used for these purposes, please notify us in writing so that our records can be updated accordingly.