Please Give Details of Any Studies You Are Currently Undertaking Or Planning to Start

/ Application for
Employment
Please note: this application form should be completed in black ink.
APPLICATIONS THAT ARE NOT FULLY COMPLETED MAY NOT BE CONSIDERED.
Please ensure that you complete all sections of the application form in full, or write ‘none’ or ‘N/A’ where appropriate.
Please do not enclose your CV instead of (or in addition to) the completed application form, as Walsingham requires your information to be in our standard format. /
Position applied for / Full-time
Part-time
Location / Minimum Guaranteed Hours
Title / Mr / Mrs / Ms / Miss / Other
First names (as stated on birth certificate) / Surname
Preferred first name (also ‘known as’) / Previous surnames
Date of birth
Telephone numbers
Address / Home
Mobile
Postcode / Email
How did you hear about this position? / Do you have a full driving licence valid for the UK?
Newspaper/Magazine / Website / Yes No
Notice/Staff Circular / If Yes, how long have you held this licence?
Current Walsingham Staff / Name: / Is your licence / Manual / Automatic
Other / Details: / Do you have endorsements on your licence?
Yes No
Are you related to any current or former Walsingham Trustees, employees or people supported by Walsingham? Yes No / Please give details of endorsements and dates
If Yes: / please give name / Endorsements will not necessarily exclude an applicant from consideration for employment.
and relationship
Have you been employed by us before? / Yes No / / Do you meet current Home Office Right to Work in the UK criteria? Yes No
Have you ever applied to us before? / Yes No
If no, please explain
If Yes, please give details of dates, position, and location: / Are there any current immigration restrictions within this? Yes No
If Yes, Please give details

Education Details

Please give details of your academic and other qualifications, obtained at school, college, and university.

Name of establishment, address & telephone number / Dates attended / Course / Qualifications
From / Month / Year
To / Month / Year
From / Month / Year
To / Month / Year
From / Month / Year
To / Month / Year

Please give details of any studies you are currently undertaking or planning to start.

From
To
From
To

Other Courses

Course / training title / Date completed / Qualification earned

Please note that if shortlisted for interview, original certificates of relevant qualifications will be required,
and a copy taken for retention with the application data.

Professional Membership

Please give details of membership of any professional institutions, positions held, etc.

Organisation / Level of membership / Reg no. / Pin no. / Date of expiry/
renewal

Voluntary Experience
Please give details of any voluntary work you consider relevant to your application.

Name of establishment;
address & telephone number / Nature of work / Dates

Employment History

In order to satisfy the Care Standards Regulations, you are required to provide a FULL employment history, from the date you left full-time education. Record the information in chronological order, with the most recent period first. Any gaps in employment should be explained in writing (e.g., unemployment dates, Job Centre details, periods of travelling).

Current/most recent employer

Previous Employers Please continue on a separate A4 sheet if necessary. Incomplete applications may be returned.

Company name / Dates of employment or employment gap / Month / Year
Contact name / From
To
Address
Including postcode / Your job title and a brief description of duties
Telephone
Fax / Salary
Email / Reason for leaving
Company name / Dates of employment or employment gap / Month / Year
Contact name / From
To
Address
Including postcode / Your job title and a brief description of duties
Telephone
Fax / Salary
Email / Reason for leaving
Personal Reference / If you are unable to provide a minimum of two employment references, we will need to obtain a personal reference from a professional person (such as a doctor, teacher, etc).
Name of referee / Address
Profession / including postcode
Length of time known
(must be at least 2 years) / Postcode:
Relationship to you / Telephone
(must not be a relative)
Recruitment Monitoring
Walsingham requires all its managers and employees to apply its Diversity Policy and not to discriminate against anyone because of nationality, sex, race, colour, ethnic or national origin, culture, age, religion, sexual orientation, marital status or disability.
To monitor the application of our Diversity Policy, we need to gather information about the people who are applying for employment with us. We would like to ask you to complete this simple questionnaire.
This form will be detached from your application prior to shortlisting. All information on this form will be treated as confidential and will be used for statistical monitoring only.
Please tick the appropriate boxes, expanding on the information where necessary.

Name
I am / Male / Female

Under the category of disability within the Equality Act 2010, do you consider yourself to have a disability or animpairment?
Yes No

What is your ethnic group?
Asian or Asian British
Bangladeshi
Indian
Pakistani
Other Asian
Black or Black British
African
Caribbean
Other Black
Mixed
White and Asian
White and Black African
White and Black Caribbean
Other Mixed
White
British
Irish
Other White
Other ethnic group
Chinese
Other
What is you Nationality?

Do you practice any religion? / Yes No
If so, please specify:
/ Application Information
If you are successful at interview, Walsingham will progress your application further by starting reference checks.
Walsingham’s reference checking policy is to obtain a minimum of two references to cover at least the last two years. Where applicable, references relating to any position which involved working with vulnerable adults or children will be sought. This will include obtaining the reason for leaving that employment, as required by the Care Quality Commission / Care and Social Services Inspectorate Wales
All offers of employment will be subject to receipt of references and an Enhanced Disclosure & Barring Service Disclosure, which are satisfactory to Walsingham.
If you need any help completing this application form, require it in another format, or have any questions about working with Walsingham, you can contact us by using the following methods:
Telephone: / 020 8343 5547
Fax: / 020 8492 0198
Email: /
Website: /
Please send your completed application form to the following address:
‘Private and confidential - for the attention
of the HR Department only’
Walsingham
Walsingham House
1331-1337 High Road
Whetstone
London
N20 9HR

Supporting Information

Please use this section to support your application and provide evidence of your suitability for the post, explain how you meet the requirements of the Job Description and Person Specification, including any additional skills and experience.

Please continue on a separate A4 sheet if necessary.

Criminal Records Disclosure
Because of the nature of Walsingham’s work, our vacancies are exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act (ROA) 1974 by virtue of the ROA 1974 Exceptions Order 1975. You are, therefore, required to disclose any criminal convictions, cautions, reprimands, final warnings or any other information that may have a bearing on your suitability for the post (this will include ‘spent convictions’, criminal charges or summons pending against you). All information will be treated in strictest confidence.
All applicants will be subject to anEnhanced Disclosure check from the Disclosure & Barring Service (DBS) before the appointment is confirmed. A criminal record will not necessarily exclude an applicant from consideration for employment. This will depend on the nature of the position and the circumstances and background of your offences. A code of practice on Disclosures is available from the DBS via Walsingham has written policies on Recruitment & Selection and Diversity, which include statements relating to the recruitment of ex-offenders - copies of these documents are available to applicants, on request.
Have you ever been convicted by the courts, or cautioned, reprimanded or given a final warning by the police?
Yes No
Are you aware of any police enquiries undertaken following allegations made against you which may have a bearing on your suitability for the post?
Yes No
If you answered ‘Yes’ for either question, please give details of offences, penalties and dates

Declaration

The information supplied by you on this form will be processed and stored in manual and computerised records for recruitment, employment and management information purposes, in line with current Data Protection Act legislation. You have a right of access to this data. All information will be treated in strictest confidence. Unsuccessful applications are retained for six months unless otherwise agreed. This application form is the initial stage of our selection process and will be used to select candidates to be interviewed. Please check that it is complete and accurate.

I declare that the information contained on this form is true and complete. I understand that if it is later discovered that any statement is false or misleading, it may be sufficient for cancelling any agreements made or I may be dismissed from employment by the company. I consent to Walsingham holding/processing this information and give my permission for reference checking in connection with my application. I understand that in the event of being successful at interview I will be required to complete a confidential declaration in respect of my state of health and an EnhancedDBS Disclosure will be sought.

If you are sending your application form by email, please type your name in the “Signed” box below to indicate that the information provided on this form is true.
Signed:
Date:
Additional Employment History Details / Name:

Please provide a FULL employment history, from the date of leaving full-time education. Any gaps in employment should be explained in writing. Record the information in chronological order, with the most recent period first.

Company name / Dates of employment or career break / Month / Year
Contact name / From
To
Address
Including postcode / Your job title and a brief description of duties
Telephone
Fax / Salary
Email / Reasons for leaving
Company name / Dates of employment or career break / Month / Year
Contact name / From
To
Address
Including postcode / Your job title and a brief description of duties
Telephone
Fax / Salary
Email / Reasons for leaving
Company name / Dates of employment or career break / Month / Year
Contact name / From
To
Address
Including postcode / Your job title and a brief description of duties
Telephone
Fax / Salary
Email / Reasons for leaving
Company name / Dates of employment or career break / Month / Year
Contact name / From
To
Address
Including postcode / Your job title and a brief description of duties
Telephone
Fax / Salary
Email / Reasons for leaving

Additional Employment History Details Continuation

Please continue on an additional sheet if necessary