Application Form

Counselling Co-ordinator..

Please complete this form in block capitals and black ink or black type.

Surname / Mr. / Mrs. / Ms. (please indicate)
Forenames / Home Tel
Address / Work Tel
Mobile Tel:
Email
Date of Birth
Please give the name of two referees. One should be your most recent employer (if appropriate)
Name / Name
Position / Position
Organisation / Organisation
Address / Address
Telephone / Telephone
Referees will not be contacted until an offer of employment has been made.
Rehabilitationof Offenders Act 1974
Because of the nature of the work for which you are applying, this post is exempt from the provisions of S4. (2) Of the Rehabilitation of Offenders Act 1974 by virtue of the Acts exemption order 1975. Applicants are, therefore, not entitled to withhold information about convictions that, for other purposes, are 'spent’ under the provisions of the Act and, in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by the Employer. Any information given will be completely confidential and will be considered only in relation to this application. (If relevant, supply details on a separate sheet of paper in a sealed envelope, marked confidential).
Have you ever been convicted of a criminal offence? YesNo
National Insurance Number / If you do not have a National Insurance Number and are called to interview, in order to comply with the Asylum and Immigration Act 1995 you willbe asked to produce evidence of your entitlement to work in the UK
I confirm that the details given in this form are correct.
Signature / Date
Send completed form to South Lakeland Mind, Stricklandgate House, 92 Stricklandgate, Kendal, LA9 4PU. Email:

Employment/Occupation.

Please tell us about the last 10 years, most recent first. Please clarify any gaps. Include voluntary work and other occupations. Add sheets if required.

Present occupation Employer ( where relevant) / Position held
Address / Duties and responsibilities
From / To
Employer ( where relevant) / Position held
Address / Duties and responsibilities
From / To
Employer ( where relevant) / Position held
Address / Duties and responsibilities
From / To
Employer ( where relevant) / Position held
Address / Duties and responsibilities
From / To

Education, Qualifications, Training

Qualification or Course / Place of study / Dates

It will be difficult to carry out some duties without a car.

Do you drive? / Do you have current endorsements? / Do you own/have access to a car?
Are you registered disabled? / Registered Disablement Person Number
If selected for interview, do we need to provide any special access or facilities?
When would you be available to start?

Personal Statement

In conjunction with the job description and person specification, tell us about any professional and personal experience, skills, knowledge and qualities you have which you feel would be of benefit to us, and would support your application. A CV alone is not adequate but you can include one if you wish. Add extra sheets if you need to.

South Lakeland Mind is an Equal Opportunities Employer Page 1 of 4REGISTERED CHARITY NO 514587