ApplicantSurname:(CAPITALLETTERS)

Pleasereturnyourcompletedapplicationformto:

Mrs A Hughes

Headteacher

StClere’sSchool Butts Lane Stanford-le-Hope Essex SS170NW

Tel:01375 641001

Fax: 01375 675814

E-mail:

Thank you for your interest in St Clere’s Co-operative Academy Trust.

The followinginformation is necessary to ensure thatfull consideration can be given to all candidates. This information given willbe treated asconfidential.

Pleasecomplete the application form inblack ink ortype and ensure you complete all the sections. The Declaration must besigned and canbe found in section 16 of this form.

This post is exempt from the Rehabilitation ofOffenders Act 1974 and thereforeall convictions, cautions andbind-overs, including thoseregardedas ‘spent’, must be declared.Any record should besealed in an envelope marked confidentialand attachedto this application.

Providing false information is an offenceand could result in your application being rejected or sum- mary dismissal if you have been selected and possible referral to the police.

Section 1

Post Details

Application for appointmentas: ClosingDate:

Do you needpermission towork in the UK? How did youhear about this post?

Personal Details

Section 2

Last name and title:
First name(s):
Previous names:
Home Address:
Home telephone number:
Mobile number:
Home e-mailaddress:
National Insurance No:

Present Employment(if currently employed)

Section 3

Employer’s name and address (if applicable)
TelephoneNumber:
Nature of business:
Job title:
Date appointed:
Grade/SalarySpine:
Current Salary (Point):
Notice required:
Allowance(s)received:Type(s):
Value(s)£
Reason for leaving:

Please tick the box if you do not wish to be contacted at work

Brief outline of duties in your current or most recent job.

Section 4

Section 5

Previous Employment Please includeall full time and part time positions.Please list the most recent first and continue on a separatesheet if necessary.

Employer: / Start
Date: / End
Date: / Job Title: / Salary/ Grade: / Reason for leaving

Breaks in Employment History

Section 6

If you have had any breaks in employment since leaving school, give details of these periods and your activities during these times e.g. unemployment, raising family, voluntary work, trainingetc.

Mobility(Please complete this section if the Person Specification for thepost includes these requirements)


Section 7

SecondarySchool EducationPlease list mostrecent firstSection 8

School(s): / From: / To: / Qualification/subject obtained & awarding body / Grade: / Dates:

Continuing Education(University/College/Apprenticeships etc.)Please list most recent first.

Section 9

Educational establishment: / From: / To: / Qualification/subject obtained & awarding body / Level/ Grade: / Dates:

Professionalqualifications Includingdetails of professional association membership

Do you hold Qualified Teacher Status (QTS)Yes NoDfES Number

If yes pleasecomplete the following:

Date Statutory Induction Period(if qualified since August 1999) started:Completed: General Teaching Council (GTC) Registration date and number:

Section 10

Other relevant training and development activities attended in the last 5years

Pleaselistthemostrecentfirstand continueonaseparatesheetif necessary

Section 11

Brief description/Course title: / Date: / Organising Body:

Information in support ofthis application

Section 12

Please use thePerson Specification/JobDescription as a prompt to describe the experience, skills, competencies and qualifications that makeyou suitable for this job.These may have been gained fromyourwork experience, any voluntaryor communityworkor any otherorganisationyoumayhave been involvedwith. You should ensure that any information submitted reflectsyour experience relating to the competencies that are detailed in the Person Specification/Job Description (please continue on a separate sheet if necessary). If youare a teacher, please

provide detailsof anyspecialist teachingexperience/skillsyou possess thatmaybe relevant to the post.

References

Section 13

Please give the names and addresses ofyour two most recent employers(if applicable). If you are unable to do this, please clearlyoutlinewhoyour referees are.

Name and address: / Nameandaddress:
Position: / Position:
Telephone number: / Telephone number:
Fax number: / Fax number:
E-mail address: / E-mail address:

Notes:(i) Refereeswill be contactedbefore interviewsunless otherwise requested (see below). (ii) If either ofyour referees knowyou byanother name please give details:

(iii)The Academy maycontact other previous employers for areferencewithyour consent. (iv) Referenceswill not be accepted from relatives or from peoplewriting solelyin thecapacityoffriends

(v)If youare currentlyworkingwith children,your current employerwillbeasked about disciplinary offences relating to children, including anywhich the penaltyis ‘time expired’ andwhetheryouhave been the subject of anychildprotection concerns, and if so, the outcome ofanyenquiryordisciplinaryprocedure.

Close Personal Relationships

Section 14

Are you a relative or partner, or do youhave a closepersonal relationship with,any employee or Governor of

St Clere’sCo-operative Academy Trust?If ‘yes’ please statethe name(s) of the person(s) andrelationship. (see notes below)

…………………………………………………………………………………………………...YesNo

Failure to disclose a close personal relationship as above may disqualify you. Canvassing of Governors or

Senior Managers by or onyour behalf is not allowed.

Pleaseconfirm the following statementsare true by signing the box below

Section 15

Declaration

I certify that, to the best of my belief, the information I have provided is true and I understand that any false information will result, in the event of employment, indisciplinary investigation bythe Academy, and is likely toresult in dismissal.

Disclosure of Criminal Convictions

Short-listed candidateswill be asked tocomplete a ‘Disclosure of CriminalConvictions’ form and, where appropriate, a Disclosurewill be soughtfrom the Criminal Records Bureau in the event of a successful application. A convictionwill not necessarily be a bar to obtainingemployment.

Safer recruitment

I certify that Iam not on list99, disqualified from working with children or subject to sanctions imposed by a regulatory body, e.g. the General Teaching Council (GTC), which would restrict me from applying for this

post and I have no convictions, cautionsor bind-overs, including thoseregarded as ‘spent’.

Data Protection Act 1998

I hereby give my consent for personal information (including recruitment monitoring data) provided as part of this application to be held on computer or other relevant filing systems and to be sharedwithother accredited organisations or agencies inaccordancewith the DataProtection Act 1998.

Correspondence

Thank you for applying for this post. Your interest in working with usis

very much appreciated.It is not practiceto acknowledge receipt of applications. However, if you would liketo be informed of the outcome of your application once the selection process has been completed, then please enclose astamped addressed envelope.

Signed:

Date:

Post title: …………………………………………….

Last name(s):……………………………………..First name(s): …………………………...... Date of birth:………………..

St Clere’s Co-operative Academy Trust iscommitted to ensurethat applicants areselected on the basis of their abilities relevant to the job.Completion of this section will helpus to ensurethat our policyand procedures are effective in avoiding discriminationand promoting equal opportunities in recruitment.

The information you provide will be usedfor monitoring and statistical data purposes only andwill not be seen by the shortlisting panel.This section will be detached from your application form prior to shortlisting.Ifyou do not wish to sharethis information, you canselect the ‘prefer not to say’option.

1. / Age
 / 15-19 /  / 35-39 /  / 55-59 /  / Prefernot to
 / 20-24 /  / 40-44 /  / 60-64 / say
 / 25-29 /  / 45-49 /  / 65-69
 / 30-34 /  / 50-54 /  / 70+

2.Gender

MaleFemalePrefernotto say

3.Ethnicorigin

Asian/AsianBritish—Bangladeshi

Asian/AsianBritish—Indian

Asian/AsianBritish—Pakistani

Asian/AsianBritish—Other

Black/Black British—African

Black/Black British—Caribbean

Black/Black British—Other

Chinese

Mixed—White and Asian

Mixed—White and BlackAfrican

Mixed—White and BlackCaribbean

Mixed—Other

White—British

White—Irish

White—Other

Other (pleasespecify)

Prefer not tosay

4.SexualOrientation

Heterosexual

Bisexual

Lesbian

Gay

Transgender

Other(pleasespecify)

Prefernottosay

The information contained on this formwill be held on a computerfile

5.DisabilityDiscriminationAct1995

Before ticking the appropriate box belowpleasefirst readthe definition of disability.

The definitionof disability, as outlined intheDisability Discrimination Act 1995 isas follows:

“A physicalor mental impairmentwhich has a substantial and long term adverse effect on a person’s abilityto carryout normal day-to-dayactivities”.

To be protected under theAct,

•an individualmust have animpairmentwhich can bephysical or mental

•it has to be substantial, that is something more thanminor or trivial

•it needs to belong term, i.e. the impairment has lasted oris likely to last in total for at least twelve month or is likely to last for the rest of the life of the person affected (long term includes conditions which fluctuate or may recursuch as cancer,HIV/AIDS and multiple sclerosis) and

•it must affect their day to day activities on a regular basis (day-to-day activities includes things such as read- ing, lifting and carrying objects, personal care,shopping, meeting and communicating with people.The ef- fect of your impairment oneveryday activities is considered as it would bewithout medicationor aids.The only exception is eyesight which shouldbe judged when anindividual is wearingtheir usual lenses orspec- tacles).

The effect animpairment may have on day to day activitiesis defined in the Act as fallingwithin the following categories:-

•mobility

•manual dexterity

•physical co-ordination

•continence

•ability to lift, carry orotherwise move everyday objects

•speech, hearing or eyesight

•memory or ability to concentrate, learn or understand or

•perception of the risk of physical danger

I do consider myself to have a disability as definedbythe Disability Discrimination Act 1995 (as detailed

above).

I do not consider myself to have a disability as definedby the Disability Discrimination Act 1995 (as detailed above).

I prefer not to say

Data Protection Act

I hereby give my consent for the Recruitment Monitoring Information provided onthis form to be held oncomputer or other relevant filing systems and to be sharedwithother accredited organisationsor agencies in accordance with the DataProtection Act 1998.

Signed

Date