APPLICATION FOR APPOINTMENT
Please read the recruitment guidance notes before completing this form
GENERAL INFORMATION
Position Applied for:
Hours of work: / Please indicate which of the following you are interested in:
Full Time Part Time/Flexible Working Any
If you are applying for the role on a part time, relief or sessional basis, please indicate when during the week you are able to work:
Where did you see this vacancy advertised? / DTV CRC Website Job Centre Plus Internal Notice
Evening Gazette Northern Echo Recruitment Fair
Other (please specify)
PERSONAL DETAILS
Please complete this section in block capitals
Forename:
Surname:
Address:
Postcode:
Phone Number(s): / Home:Mobile:
Email Address:
National Insurance No:
Under the Asylum and Immigration Act 1996, employers must check that potential employees are entitled to live or work in the United Kingdom. Are you entitled to or do you have permission to work in the United Kingdom? / YES / NO (delete as appropriate)
REFERENCES
Please give details of two independent references from whomDTV CRC will seek information regarding your suitability for this job. One of which should be your current or most recent employer. For DTV CRC employees or volunteers, your current Chief Executive Officer)
Referee No 1:
Name
Occupation
Address (including postcode)
Email Address
Referee No 2:
Name
Occupation
Address (including postcode)
Email Address
EDUCATION & QUALIFICATIONS
Starting with the most recent, please give details of all qualifications you hold. You should include qualifications that are ongoing.
University / College / School: / Date of qualification: / Qualifications gained: / Grades:
TECHNICAL OR PROFESSIONAL MEMBERSHIP
Institute: / Grade of membership: / Date obtained:
TRAINING
Please give details of any additional training undertaken which you feel is relevant to the role. Please include dates of completion.
CURRENT (OR MOST RECENT) EMPLOYMENT
Please provide details of your current or most recent employment
Name & Address of Employer:
Dates of employment: / From:To (if applicable):
Job Title:
Brief details of responsibilities:
Current salary (per annum):
Reason for leaving/seeking alternative employment
EMPLOYMENT HISTORY
List of all employment including unpaid or voluntary work. Please also include any gaps in employment including reasons for these gaps..
Name & Address of Employer: / Dates employed: / Job title and main duties: / Reason for leaving:
Have you ever been dismissed or asked to resign? If yes please give details: / YES / NO (delete as appropriate)
REASONS FOR APPLYING
Please give your reasons for applying for this role:
Please provide a detailed statement of the skills, knowledge and experience that makes you suitable for this job. (Please make reference to the person specification and include examples where possible)
CONVICTIONS
For roles involving direct contact with participants, please note that spent and unspent offences under the Rehabilitation of Offenders Act 1975 must be declared. For roles that do not involve direct contact, only unspent offences need to be declared. Previous convictions will not necessarily disqualify you from appointment.
Have you ever been convicted of a criminal offence? / YES / NO (delete as appropriate)
If yes, please give details of offences, including date of conviction and sentence:
Have you ever received a Police Caution, Reprimand or Warning? / YES / NO (delete as appropriate)
If yes, please give details of offences, including date of Caution/Reprimand/Warning:
OTHER ISSUES
Are you, or have you ever been, a member of a group or organisation which has racist aims, philosophy, principles or policies? If yes, please give details. / YES / NO (delete as appropriate)
If you have previously been employed within a provider of Probation Services, including the NPS, in an operational practitioner role have you ever had your authorisation as an “Authorised Person” suspended temporarily or removed permanently? If yes, please give details. / YES / NO / NOT APPLICABLE (delete as appropriate)
DRIVING AND MOBILITY
Do you hold a full driving licence? / YES / NO (delete as appropriate)
Do you have access to a car? / YES / NO (delete as appropriate)
Have you any endorsements? / YES / NO (delete as appropriate)
If yes, please provide details.
AVAILABILITY
Please indicate any notice you are required to give your current employer: (if applicable)
Are you able to attend the assessment/interview dates specified in the advert? / YES / NO (delete as appropriate)
Do you have any annual leave or holidays currently booked? Please provide dates.
DECLARATION
I declare that the information provided on this application form is full, accurate and complete and I understand that if I provide false information or fail to provide full, complete and accurate information, this may lead to the decision that my application cannot be considered further, the withdrawal of offer of appointment, or by my dismissal, without notice, if I have been appointed.
Signed:
Date:

Please return your completed application form and diversity monitoring to:

or:

People Resources Unit

DurhamTeesValleyCommunity Rehabilitation Company

Wetherby House, Wetherby Close

Portrack Interchange Business Park

Stockton on Tees, TS18 2SL

If you have any queries please get in touch using the above email address.

DIVERSITY MONITORING
Position applied for:
Gender: / Male Female Do not wish to disclose
Date of Birth: / Age:
Marital Status: / Please select the option which best describes your marital status.
Single Married Civil Partnership
Divorced Separated Widowed
Do not wish to disclose
Race & Ethnic Origin: / Please show which group best describes your race and ethnic origin by ticking one of the boxes below.
W1 White: BritishA1 Asian or Asian British: Indian
W2 White: IrishA2 Asian or Asian British: Pakistani
W9 White: OtherA3 Asian or Asian British: Bangladeshi
M1 Mixed: White & Black CaribbeanA9 Asian or Asian British: Other
M2 Mixed: White & Black AfricanB1 Black or Black British: Caribbean
M3 Mixed: White AsianB2 Black or Black British: African
M9 Mixed: OtherB9 Black or Black British: Other
01 Chinese09 Other ethnic group
Do not with to disclose
Religion: / Please show which option best describes your religion by ticking one of the boxes below.
Christian Budhist
Hindu Jewish
Muslim Sikh
No religion Do not wish to disclose
Disability: / Do you consider yourself to be disabled within the meaning of the Equality Act 2010?
Yes No Do not wish to disclose
If yes, please tick any of the following which apply to you. You may identify more than one.
Hearing Impairment
Speech Impairment
Visual Impairment (not corrected by glasses or contact lenses)
Reduced Mobility
Progressive Condition (eg Cancer, muscular dystrophy, HIV)
Reduced Physical Capacity including difficulty with physical co-ordination
Severe disfigurement
Mental Illness
Learning Difficulties
Dyslexia
Other (please specify)
Do not wish to disclose
If applicable, what obstacles and barriers do you face in day to day activities?
If applicable, what facilities, equipment or other support do you need to carry out normal day to day activities?
Name:
Signature:
Date:
Office use only
App no: