Reference No:
Where did you see this post advertised?
PERSONAL DETAILS
First Names / Telephone
Surname / Home
Address / Work
Mobile
Postcode
National Insurance No / Yes No
If you are not a member of the European Community, do you require a work permit to work in the UK? / Yes No
Do you require a visa to work in the UK? / Yes No
If required, do you hold a valid visa? / Yes No Expiry Date
If yes, please state the type of visa?
EDUCATION
ACADEMIC QUALIFICATIONS
(degrees, A-levels, GCSEs – where and when gained starting with the most recent) / Date / Grade
Presentation of original certificates will be required on appointment
FURTHER EDUCATION Please give details of any courses currently being undertaken
MEMBERSHIP OF PROFESSIONAL ORGANISATIONS AND QUALIFICATIONS RELEVANT TO YOUR APPLICATIONPlease give membership number, status and expiry date
OTHER TRAINING Please give details of any other relevant training received, skills or courses you have undertaken
CURRENT OR MOST RECENT EMPLOYER
Name and address:
Dates employed: / From: / To:
Job title:
Brief description of duties:
Reason for leaving: / Annual salary:
Period of notice:
EMPLOYMENT HISTORY
EMPLOYER’S NAME & ADDRESS / JOB TITLE / REASON FOR LEAVING / DATES EMPLOYED
From --/--/-- / To --/--/--
PLEASE GIVE REASONS FOR ANY GAPS IN EMPLOYMENT
DEMONSTRATION OF YOUR SUITABILITY FOR THE ROLE
This is an important part of the application and your chance to tell us why you feel you are a suitable candidate for this post. We recommend that you read the job description and person specification thoroughly before you answer this section as we draw up a short list on the basis of this information.
Please indicate briefly (no more than 1500 words) why you are applying for this job. You should highlight here particular skills and previous experience you have relevant to this role and provide clear examples of these.
Please continue on a separate sheet if necessary
REFERENCES
Please provide full contact details of two separate employers, one of which must be your current employer, or if not currently employed, your most recent employer.References must cover at least the last three years of employment. The reference from your current or last employer should be a senior person to whom you report and who knows your work. Referees must be able to comment on your work ability. Please do not give friends or relatives. Please note Refuge reserves the right to contact any of your past employers and is unable to accept recruitment agencies as referees. All offers of employment are conditional and subject to references satisfactory to Refuge and pre-employment checks, including Disclosure and Barring Service certificate where relevant.
Name / Name
Job Title / Job Title
Employer Name /Address / Employer Name / Address
Tel No / Tel No
Fax No / Fax No
Email / Email
Relationship of referee to you / Relationship of referee to you
May reference be taken up before interview?
YES/NO / May reference be taken up before interview?
YES/NO
REHABILITATION OF OFFENDERS ACT 1974
Because of the nature of Refuge’s work some of our posts are exempt from Section 3 (2) of the Rehabilitation of Offenders Act 1974 (Exceptions) order 1975 (as amended in 2013). Where posts are exempt, this will be stated on the person specification.
Applicants for such posts are therefore not entitled to withhold information about convictions which for other purposes are “spent” and which are not “protected” under the provisions of the Act. In the event of employment, any failure to disclose such convictions will result in dismissal or disciplinary action by Refuge. Any information given will be treated as confidential.
Further information is available at
If the role you are applying for requires a DBS certificate, please complete the declaration and agreement below.
Do you have any unspent convictions, cautions, reprimands or warnings? Are you currently subject to criminal investigations or procedures?
Yes No
If yes, please declare details in a sealed envelope marked for the attention of the ‘Deputy Head of Human Resources – Private and Confidential’.
The information disclosed will be treated as confidential and will only be seen by appropriate individualsinvolved in the recruitment process.
Having a criminal record will not necessarily bar you from working for Refuge. Consideration will be given to extenuating circumstances, the nature and relevance of the offence and any potential risks involved. If there are significant discrepancies between the information declared and the information on the Disclosure received, it will be necessary for Refuge to consider whether or not to withdraw a conditional offer of employment. We will discuss any matter revealed with the candidate prior to making a final decision.
Agreement to Complete a Disclosure and Barring Service Check
Position applied for: (please complete) ………………………………………
I understand that the position for which I have applied (as stated above) is subject to a Disclosure and Barring Service (DBS) certificate. I hereby give my consent for Refuge to carry out a DBS check if I am to be made a conditional offer for this position.
As it is a requirement to have a satisfactory enhanced DBS certificate for roles that include regulated activity failure to give consent would result in the withdrawal of any conditional offer. An enhanced certificate details convictions, cautions, reprimands and warnings held in England and Wales on the Police National Computer (and most of the relevant convictions in Scotland and Northern Ireland may also be included). In addition it includes a check of the barred persons lists and any locally held police force non conviction information considered relevant to the job role by the relevant Chief Police Officer(s).
Signed ……………………………………. Date……………………………………
Print name……………………………………………………………………………..
OTHER QUESTIONS
Please give any dates over the coming weeks when you will be unavailable for interview
Do you consider yourself you have a disability? Yes No
As part of our commitmentsunder the Disability Symbol this information is needed so that all disabled applicants who meet the essential criteria for this position are offered an interview. The Equality Act (2010) defines disability as a “physical or mental impairment that has a substantial and long-term adverse effect on the ability to carry out normal day to day activities.”
Do you have a current driving licence? Yes No
Do you have use of a car during working hours? Yes No
Do you know or are you related to any member of Refuge’s Council of Management or any other employee/ volunteer at Refuge? Yes No If yes, please give details
Are you involved with any other organisations in a paid or voluntary capacity? Yes No If yes, please give details
NOTE
If any particulars given by you are found to be false, or if you wilfully omit or suppress any information or factsdirectly relevant to the position this will lead to the withdrawal of the offer of employment or the subsequent termination of employment. Any canvassing, direct or indirect, for appointments or contracts with Refuge is strictly prohibited and will disqualify candidates.
The information provided by you on this form and by any referees, will be processed by Refuge while considering your application for employment or if you are successful in your application for employment. If successful Refuge will check that the information provided is correct, including information relating to employment, qualifications and skills. Information may be passed to third parties where permitted as required by law. In signing, or electronically submitting this application you consent to the processing of your data, both manual and electronic including sensitive data, in accordance with the Data Protection Act 1998.
DECLARATION
In accordance with the Data Protection Act 1998, I give consent for the information contained in this form to be processed inline with Refuge’s recruitment and employment practices. I understand that, if I am appointed, this application form willbecome part of my personal file and that, if I am not appointed, it will be stored for 12 months and then destroyed.
I declare that the statements made by me in this application, including the supplementary questions and any other details that I have submitted as part of the recruitment process, are true to the best of my knowledge and belief. I give permission for you to seek confirmation of the details supplied in my application. I understand that Refuge reserves theright to withdraw any offer of employment or to terminate employment already commenced if the information given isinaccurate or misleading in any way. Any job offer is conditional upon references and pre-employment checks considered satisfactory by Refuge and, if required by Refuge, anymedical reports.
Signed: Date:
Please return this form to
Please note that this form can be submitted electronically (without signature) but if you are short-listed and attend interview you will be required to bring a signed copy of the application form with you on the day.
Please now complete the Diversity Questionnaire below.
1.1CONFIDENTIAL DIVERSITY QUESTIONNAIRE
/We are committed to ensuring that every applicant applying for a post at Refuge is treated fairly.
Our recruitment processes are carried out in a way that ensures that individuals are selected purely on the basis of their ability to the job for which they have applied. No job applicant or employee will receive less favourable treatment on the grounds of sex, marital status, disability, race, ethnic origin, nationality, age, sexual orientation, religious belief or political opinion or be disadvantaged by conditions or requirements which are not justified or relevant to the job. The only requirement for selection is the suitability of the applicant for the post.
The human resources team will treat the following information as confidential and we would appreciate your co-operation in helping us monitor the effectiveness of our equality and diversity policy. Your responses will be treated in confidence and used for statistical monitoring except in the case of disability where it will be used to identify reasonable steps that we can take to help you through the selection process. The “Questions and Answers” section at the end of the form gives more detail. Your application will not be affected by the information provided and will be separated from your application form on receipt. Answering the questions below is voluntary, but your co-operation would be of great value.
This form is divided into sections. Youare asked to complete all sections.
FULL NAME:- ETHNIC ORIGIN
Choose ONE section from A to F, and then tick the appropriate box to indicate your cultural background.
AWhite
English
Scottish
Welsh
Irish
Any other white background, please specify / B Mixed or Mixed British:
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background, please specify
C Asian or Asian British:
Indian
Pakistani
Bangladeshi
Any other background, please specify / D Black or Black British:
African
Caribbean
Any other black background, please specify
E Chinese or Chinese British:
Chinese
Any other background, please specify / F
Not declared
- DISABILITY
- “substantial” means more than minor or trivial
- “long term” means that the effect of the impairment has lasted or is likely to last for at least 12
- “Normal day to day activities” include everyday things like eating, washing, walking and going
People who have had a disability in the past that meets this definition are also protected by the Act.
Do you consider yourself to have a disability? Yes No
If yes, please provide details of your disability and specify any adjustments we could make to accommodate your needs
- GENDER
- AGE (please tick the appropriate box)
45 – 54 55 – 64 65 +
- RELIGION OR BELIEF
Buddhist Hindu Jewish Muslim Sikh
Other Religion/Belief, please specify No religion/ belief
- CARING RESPONSIBILITIES
If ‘Yes’ are they?
Children under 16 Sick or Elderly Disabled
ADDITIONAL INFORMATION
Where did you see this position advertised?
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE
QUESTIONS AND ANSWERS
What information will be collected?
This questionnaire asks you to categorise yourself by ethnic group, disability, gender, religion/belief, sexual orientation and whether you have care responsibilities. This data will be added to the information that is held on the computerised system in the human resources team.
What will happen to the monitoring form?
The form will be opened by a member of the human resource team who will be responsible for the safe storage of the form until the data is entered onto the computer. Only human resource colleagues have access to the computer system.
What will the information be used for?
This form will contain sensitive personal data which will be processed in accordance with the Data Protection Act 1998.
The data will help us to review employment policies and practices particularly relating to the diversity of our workforce.
Workforce Analysis is regularly carried out and actions taken to address findings. Individuals are not identifiable on any reports or summaries.
Who can I contact for additional information?
Should you require any further information or advice, please contact a member of the human resources team.