/ Job Application Form
Application for post of: Carers’ Support Co-ordinator (Mental Health)
How did you come to be aware of this job vacancy?
PERSONAL DETAILS
Family Name
(Mr/Mrs/Ms/Miss) / Forenames
Address: / Tel No (Home):
Mobile No
Nat. Ins. No.
E-mail address:
Please state maiden name if applicable:
Are you related to any member or employee of Hillingdon Mind? YES/NO
If yes, please provide names and state relationship:
EDUCATION & PROFESSIONAL QUALIFICATIONS
(Documents as proof of qualification may be required at interview)
Secondary Schools, Colleges,
University / Examinations Taken / Result

Please list any other relevant course attended or qualification achieved with their dates:

CAR LICENCE
Do you hold a current driving licence? YES/NO / Do you own a car? YES/NO
PRESENT OR MOST RECENT POST
Title of Post: / Business of Employer:
Name and address of Employer: / Date commenced:
Date ended if not current post:
Please outline your responsibilities, to whom responsible and staff responsible to you (if applicable):
Reason for leaving or wishing to leave:
Period of notice required to terminate present employment:
PREVIOUS EMPLOYMENT (Most recent first)
Employer / Position held / Date From / Date To
RELEVANT EXPERIENCE, INTERESTS AND VOLUNTARY ACTIVITIES
Please describe here how your knowledge, experience and skills match those required for this post – it is important to address each aspect of the Person Specification. Your interests or voluntary activities may support your application. Please use a continuation sheet if necessary.
HEALTH
Please state the number of days sickness absence in the last 2 years:
DISABILITY DISCRIMINATION ACT 1995
Do you consider you have a disability under the Disability Discrimination Act?: YES/NO
If yes, please list any adjustments which you think we could make to overcome you disability in relation to the essential requirements of this job:
REHABILIITATION OF OFFENDERS ACT 1974
This post is subject to an Enhanced DBS Check and is regarded as exempt under the Rehabilitation of Offenders Act 1974. You are required to declare whether or not you have any criminal convictions even if they could otherwise be regarded as spent. If you do not have any convictions please write NONE

Please declare any unspent convictions on a separate sheet and tick this box if doing so:
(and submit in a sealed envelope with this application)
REFERENCES
Names and addresses of two referees, one of whom should be your current or most recent employer
Name:
Position:
Address:
Tel No:
Email Address:
Relationship to you: / Name
Position:
Address:
Tel No:
Email Address:
Relationship to you:
May we make contact prior to interview: YES/NO / May we make contact prior to interview: YES/NO
DECLARATION
I declare that the information given is true and correct. I give my consent to my referees being contacted as indicated and for details of any sickness over the past two years to be obtained. I confirm that I have the right to work in the UK. I understand that canvassing in relation to this post will lead to the disqualification of my application.
Signed……………………..…………………… Date………………….…….…
Please note that failure to disclose relevant details or a deliberate attempt to falsify information may lead to dismissal.
Thank you for completing this application.
Please return by 12.00 noonTue 02 May2017, marked: “Confidential – Job Application” to:
The Director
Hillingdon Mind
Aston House
Redford Way
Uxbridge UB8 1SZ / Data Protection Act 1998:
The use of information provided on this form will comply with the requirements of the above act. It may be processed by computer and for operational, managerial information and associated purposes relevant to the maintenance of Hillingdon Mind administrative systems. Such data may also be used to produce depersonalised statistics.

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