STRICTLY CONFIDENTIAL - GOVERNOR APPLICATION FORM

Please note that Khalsa Science Academy implements rigorous child protection and safeguarding systems, as a consequence CVs cannot be accepted and will be destroyed on receipt.

Please complete ALL sections of this form as appropriate.

Once completed this form should be returned to Sukhraj Singh Gill, Khalsa Education Trust, c/o Khalsa Science Academy, 192a Chapeltown Road, Leeds, LS7 4HZ.

Section 1: Personal details

Title: / Last Name:
First Name(s): / Former Names:
Home Address:
Post Code:
Day/Work Tel: / Mobile Tel:
Email: / Home Tel:

If, to your knowledge, you are related to any Khalsa Science Academy employee, Trust

Member or Governor of the Academy to which you are applying, please give details.

Section 2: Details of relevant training/qualifications

Please list any training or qualifications you have received which you feel may help you in your role as Governor:

Section 3: Employment details

Please complete the following, starting with your current or most recent employer. Please also include any breaks in employment history together with the reason for the break.

Present or Most Recent Employment

Present Job Title:
Date Appointed: Date Left (if applicable):
Name of Employer:
Address:
Telephone Number:
Key Responsibilities:

Previous Relevant Experience/Employment

Date / Employers/organisation / Position Held
From / To

Section 4: Your application

Please tell us why you would like to become a school governor. Share with us what experience, skills and personal qualities you feel you would bring to the role.

Section 5: Convictions

Please complete the following, Rehabilitation of Offenders Act 1974 (exceptions) Order 1975

The position for which you are applying involves contact with children and is exempt from the Rehabilitation of Offenders Act 1974 and all subsequent amendments. For these positions you are not entitled to withhold information regarding previous criminal convictions, including cautions, for any offences (not just those involving children) which for other purposes are ‘spent’ under the provisions of the Act.

Failure to disclose any previous convictions (including cautions) could result in dismissal should it be subsequently discovered. Any information given will be entirely confidential and will be considered only in relation to this application.

Date / Type of offence / Sentence/Fine imposed / Comments

Section 6: References

Please provide the names, addresses and occupations of two referees (one of whom must be your present or most recent employer) who are willing to support your application.

Name: Address:

Post Code: Telephone number:

E-mail address:

Name: Address:

Post Code: Telephone number:

E-mail address:

Section 7: Data protection

The information collected in the form will be used in compliance with the Data Protection Act 1998. The information is being collected for the purpose of administering the recruitment and training of governors of Khalsa Science Academy. The information may be disclosed, as appropriate, within the academy, to Academy Governors, to the Department for Education, and relevant statutory bodies. You may also note that because we have a duty to protect public funds we handle, we might need to use information you have provided on this form to prevent and detect fraud. We may also share this information for the same purposes with other organisations, which handle public funds.

Section 8: School Governor Eligibility Declaration

All governors are asked to sign a self-declaration proforma to confirm that they are eligible to be a governor. Please see the list below which details when a person is not eligible to serve as a school governor as laid down by School Governance (Constitution) (England) Regulations 2003 (regulation 20 and Schedule 6). Please read these carefully. If you are happy that none of the criteria apply to you, please sign and date the form and return it directly to the school. If you are unsure whether you are eligible or not please contact Governor Support Service on 0113 247 5564 for clarification.

People may not serve as school governors who:

·  are at any time during their period of office detained under the Mental Health Act 1983(c);
·  have failed to attend the governing body meetings for a continuous period of six months, beginning
with the date of the first meeting they failed to attend, without the consent of the governing body
(not applicable to ex officio governors);
·  their estate has been sequestrated and the sequestration has not been discharged, annulled or reduced;
or they are the subject of a bankruptcy restrictions order or an interim order;
·  are subject to a disqualification order or disqualification undertaking under the Company Directors Act 1986, a disqualification order under Part 2 of the Companies (Northern Ireland) Order 1989, a
disqualification undertaking accepted under the Company Directors Disqualification (Northern Ireland)
Order 2002, or an order made under section 492(2)(b) of the Insolvency Act 1986 (failure to pay under
county court administration order);
·  have been removed from the office of charity trustee or trustee for a charity by the Charity Commissioners or High Court on grounds of any misconduct or mismanagement, or under Section 7 of the Law Reform (Miscellaneous Provisions) (Scotland) Act 1990 from being concerned in the management or control of any body;
·  are included in the list of teachers or workers prohibited or restricted from working with children or
young people;
·  are disqualified from working with children;
·  are disqualified from being an independent school proprietor, teacher or employee by the Secretary of
State for Education and Skills;
·  have received a sentence of imprisonment (whether suspended or not) for a period of not less than
three months (without the option of a fine) in the five years before becoming a governor or since
becoming a governor;
·  have received a prison sentence of 2.5 years or more in the 20 years before becoming a governor;
·  have at any time received a prison sentence of five years or more;
·  have been fined for causing a nuisance or disturbance on school premises during the five years
prior to or since appointment or election as a governor;
·  refuse an application being made to the Disclosure Baring Service (DBS) for a criminal records certificate.

I confirm that I am eligible to be a school governor. I do not fulfill any of the above disqualification criteria. I certify the information contained on this form is to the best of my knowledge true.

Signature ……………………….…………… Date …………………………………..

Equal opportunities

Khalsa Science Academy is committed to ensuring equality of opportunity. Your application will be considered on your ability ONLY. The information requested below will be treated confidentially and will ONLY be used to monitor the Academy practices. If you fail to complete this page fully, your application will not be accepted.

Gender (Please tick)

Male  Female 

Ethnicity

Please tick appropriate box:

White

British 

Irish 

European 

Any other white background 

Black or Black British

Caribbean 

African 

Any other black background 

Chinese, Yemini or other ethnic group

Asian or Asian British / Chinese / 
Indian /  / Yemini / 
Sikh /  / Other / 
Pakistani / 
Bangladeshi /  / Mixed
Any other Asian  / White Black Caribbean / 
White Black African / 
White Asian / 
Any other mixed background / 