Application for:
Home Matters Coordinator (Hitchin) / Closing date
20th August 2009

Please complete in black ink

Mr Mrs Miss Ms
Dr Other / Surname / Forenames
Address / Postcode
Home Telephone number
Mobile telephone number / Work telephone number May we ring you at work?
Yes No
Email address

References

Please give details of three references, one of whom should be your present or most recent employer

Name
Telephone no. / Address
Postcode
How does this referee know you?
Name
Telephone no. / Address
Postcode
How does this referee know you?
Name
Telephone no. / Address
Postcode
How does this referee know you?

Convictions Please give details below of any convictions other than a motoring offence, including date and sentence imposed. Some positions may be exempt from Section 4(2) of the Rehabilitation of Offenders Act 1974 (exemptions) Order 1975. Please declare any convictions which would otherwise be considered as spent under this Act. If your application is successful a Criminal Records Bureau Disclosure will be sought. A positive declaration will not necessarily preclude you from employment.

Current employment

Name and address of current employer / Job title
Full time / Part time
No of hours? / Date you were appointed / Notice required
Summary of duties
Previous employment. Most recent first
Please do not leave any gaps unaccounted for.
Date month/year Name of employer Job held/main Reason for leaving
From To duties

Continue on separate sheet if necessary

Education, qualifications and training

Education from age 11

School/College/University / Qualifications gained including grades

Other courses attended/attending

Organising body / Course title/subject detail

We are aware of our obligations to employees under the Disability Discrimination Act. Do you have a health problem or disability which is relevant to your application? If so, please describe it here

How many days sick leave have you taken in the last twelve months?
Do you hold a current driving licence
Do you have access to your own transport

Other information

Please use this page to tell us why you have applied for this post, giving details of relevant experience, as well as knowledge of issues encountered by older people. Describe specific skills you have which relates to the job description for this post.

Describe how you match the person specification for this post - preference will be given to applicants who match their skills and experience with the criteria outlined in the person specification.

Describe any aspects of the post you feel less experienced in.

You may use a word processor to complete this section if you wish.

Please continue on a separate sheet if necessary

If appointed when would you be able to take up work?
Where did you hear of this vacancy?
Are you, to your knowledge, related to any member of staff or officer of Age Concern Hertfordshire? If so, please give details.

All applicants

I declare that the information given on this form is true and correct to the best of my knowledge. I understand that the giving of false information will disqualify me from consideration for the post or dismissal should evidence to the contrary come to light after appointment
Signed Date

When completed please return this form to:

Age Concern Hertfordshire Ltd

1 Silver Court,

Watchmead,

Welwyn Garden City,

Hertfordshire.

AL7 1LT

Telephone No. (01707) 386060

Your application form may be supported by your curriculum vitae but all sections of the form must be completed.

If you have any questions you would like answered before completing your application please do contact us at the above address or email to

.

website: www.acherts.org.uk

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