Relate Mid Surrey Counsellor in training placement application

CONFIDENTIAL

CLOSING DATE

• Please fill in all sections

• Do not attach your CV as it will not be considered

• Complete in black ink or typescript for copying purposes

PERSONAL (In Block Capitals or Typescript, please)
Surname:
Address:
(Include Post Code)
Daytime Telephone:
Email address:
Date of Birth: / Other Names:
Evening Telephone:
Do you have a current,
full driving licence?
EDUCATION/QUALIFICATIONS AND TRAINING
Please include all relevant qualifications obtained and other training courses attended
ESTABLISHMENT / DATE(s)
OBTAINED/ATTENDED / QUALIFICATION(s)/TRAINING
PRESENT OR MOST RECENT OCCUPATION
ORGANISATION / JOB TITLE / DATE
COMMENCED / DATE LEFT
(If applicable) / SALARY
Brief description of your role (and, if applicable, your main reason for leaving):
PREVIOUS OCCUPATIONS (Please enter most recent first)
ORGANISATION / JOB TITLE
(Clarify if necessary) / FROM
(Month/Year) / TO
(Month/Year) / REASON FOR
LEAVING

REHABILITATION OF OFFENDERS’ ACT, 1974

Have you been convicted of a criminal offence (other than “spent” convictions under the 1974 Act)?

YES/NO

If “Yes”, please give details. ------

EXPERIENCE AND SKILLS
Please give an account for why you feel you should be considered for a placement opportunity. Please provide a short statement of no more than 500 words giving an account of why you wish to offer relationship counselling and the relevant skills you feel you already have which equip you for the role.
REFERENCES (In Block Capitals or Typescript, please)
Please give details of two referees who are able to comment on your suitability (please note these referees will not be contacted without your prior agreement).
NAME:
ADDRESS (Include Post Code)
POSITION:
TEL NO:
EMAIL Address:
Capacity in which known / NAME:
ADDRESS (Include Post Code)
POSITION:
TEL NO:
EMAI Address:
Capacity in which known
Your referees will be contacted only if you are short-listed for interview. If such an arrangement is unacceptable to you, please tick this box.

REHABILITATION OF OFFENDERS
Because of the nature of the work for which you are applying, this post is exempt from the provisions of 4 (2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1976. You are therefore, not entitled to withhold information about convictions which for other purposes are ‘spent’ under the provisions of the Act. In the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information will be treated as strictly confidential.
Do you have any convictions? Yes / No
If Yes, please give details including the nature of the offence, dates, length of sentence.
HOW DID YOU HEAR ABOUT THIS VACANCY?
DECLARATION
I declare that the above information is true and complete and understand that any wilful misrepresentation or omission may result in dismissal. I also understand that any appointment will be subject to a satisfactory health clearance and a Criminal Records Bureau Disclosure being completed.

Please return this completed application form and the equal opportunities form to

You will be notified in due course whether or not your application has been short-listed.

Committed to Equal Opportunities

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