APPOINTMENT APPLICATION FORM

Position: Treasure and Secretary

Trustee/ Non-Executive Director

Please complete the form in BLOCK CAPITALS or typescript and attach your CV.

SECTION 1: PERSONAL DETAILS

Title (Mr/Mrs/Miss/Ms/Other [please specify])

Surname/Family Name

First Name(s)

Home Address (including Postcode)

SECTION 2: PERSONAL PROFILE – EXPERIENCE

Please outline why you want to become a trustee of KYRA and say what you believe will be the most important contribution you can make.

Using examples from your personal or professional life, please indicate in the box below how you meet the criteria outlined in the role profile.

The KYRA trustee board also needs a range of professional skills among its members. Please mark the appropriate box and tell us below about your skills and experience in any of the following areas.

X / X
Management / ☐ / Marketing / ☐ /
Income generation / ☐ / Equality and Diversity / ☐ /
Human Resources / ☐ / IT and Data Protection / ☐ /
Business development / ☐ / Media and publicity / ☐ /
Fundraising / ☐ / Governance / ☐ /
Law / ☐ / Other (please specify) / ☐ /
Finance / ☐ / ☐ /

Skills and Experience

SECTION 3: POTENTIAL CONFLICTS OF INTEREST

Please give details of any business or other interests or any personal connections which, ifyou are appointed, could be misconstrued or cause embarrassment to KYRA. These could include financial interests or shared ownership, membership of societies,activities, associations or employment of a partner or friend in the particular field in which

KYRA operates.

Any potential conflicts of interest detailed here will not prevent you going forward tointerview but may, if appropriate, be explored with you during your interview to establishhow you would address the issue(s) should you be successful in your application.

Failure to disclose such information could however result in an appointment beingterminated.

SECTION 4: DISCLOSURE

Declaration of Eligibility

I confirm that I am eligible to act as a trustee because:

  • I am at least 18 years old
  • I do not have an unspent conviction for an offence involving dishonesty or deception
  • I am not currently declared bankrupt (or subject to bankruptcy restrictions or an interimorder)
  • I do not have an individual voluntary arrangement (IVA) to pay off debts with creditors
  • I am not disqualified from being a company director
  • I have not previously been removed as a trustee by the Charity Commission or the HighCourt due to misconduct or mismanagement
  • I am not disqualified or barred from acting as a trustee of this charity under theSafeguarding Vulnerable Groups Act 2006
  • I do not have any criminal convictions (even if spent)

Have you ever undergone a DBS check? NO / YES

Being an KYRA trustee may involve working with vulnerable people, so you are required todeclare any convictions you may have, even if they would otherwise be regarded as ‘spent’under the Rehabilitation of Offenders Act 1994 (exemptions) Order SI1975, Schedule 1 part 2

(amended by SI1986).

Failure to declare a conviction will disqualify you from appointment or result in terminationof membership if the discrepancy comes to light. A DBS check is required for each trustee.

SECTION 5: REFERENCES

Please give the details of two people who may be asked to act as referees for you. They willbe expected to have authoritative and personal knowledge of your achievements. The firstreferee will be asked to comment on you in a professional capacity and the second in a

personal capacity. The referees will be approached only if you are to be recommended forappointment.

Reference 1: Professional/Achievements

Name
Address
Telephone
Email

Reference 2: Personal

Name
Address
Telephone
Email

SECTION 6: DECLARATION

I declare that the information given on this application is complete and correct to the best ofmy knowledge. I have also read the information pack and can confirm that I am eligible to beconsidered for appointment to this body. I also certify that I will immediately inform KYRAof any changes in circumstances that affect the answers I have given.

Signed …………………………………………………………………….

Date ……………………………….