Please remember to:
1.Read the application pack thoroughly before completing this form;
2.Complete in black ink using BLOCK CAPITALS when handwriting or black typescript;
3.Ensure that the form is signed and dated in the relevant places; and
4.Ensure any enclosures you wish to supply are attached to the form.
1.Personal Details
Title:
Family Name:
Forenames:
Home Address:
Postcode:
Home Telephone No: / Personal Mobile No:
Personal E-mail:
Current Occupation
(If Applicable)
Business Address (If Applicable)
Postcode:
Telephone No: / Mobile No:
Business E-mail:
2.Referees
Please give the details of two people who we may approach that are prepared to act as referees for you. They will be expected to have authoritative and personal knowledge of your achievements. Please tell us whether the referee will be able to comment in a professional or other activity-based capacity or in a personal capacity. The referees will only be approached if you are invited for interview.
In order to preserve the highest standards of integrity and propriety we are unable to accept Assembly Members or Welsh Government employees as referees for applications for Non Executive Directors.
I confirm that references, if needed, can be obtained from the following, who have agreed to act in this capacity:
First Referee:
Address:
Postcode: / Telephone:
Fax: / Mobile:
E-mail:
Current Occupation: (if applicable)
In which capacity can this person offer a reference for you:
PersonalProfessional/Work/Voluntary
Second Referee:
Address:
Postcode: / Telephone:
Fax: / Mobile:
E-mail:
Current Occupation: (if applicable)
In which capacity can this person offer a reference for you:
PersonalProfessional/Work/Voluntary
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3.Other Relevant InformationTime Requirement
The minimum requirement for serving on the Civil Service Board of the Welsh Government is 3 days per month (please see the Information for Candidates for further details). Please confirm how many days per year you can commit to serving on the Board.
I confirm that I can commit ______days per [week/month/year]serving on the Board.
Signed: / Name in CAPITALS:
Information Sharing
Sometimes we are alerted to opportunities for public appointments to bodies outside the Welsh Government’s direct responsibility (e.g. from other government departments, regional/local bodies, etc.). Please indicate if you are content for us to pass on your contact and biographical details by ticking the appropriate box and signing in the space below.
Yes: / No:
Signed: / Name in CAPITALS:
Conflicts of Interest
Please give details of any business or other interests or any personal connections which, if you are appointed, could be misconstrued or cause embarrassment to the Board or the Welsh Government. These could include financial interests or share ownership, membership of societies, activities, associations or employment of a partner or friend in the particular field in which the public body operates.
Any potential conflicts of interest detailed here will not prevent you going forward to interview but may, if appropriate, be explored with you during your interview to establish how you would address the issue(s) should you be successful in your application.
Yes: / No:
If YES, please give full details:
You may continue on a separate sheet of paper if necessary clearly identifying the question you are responding to.
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4.Evidence of Suitability for AppointmentPlease provide a short statement outlining what you feel you could contribute to this role, taking into account the role description and person specification contained in the information pack. Please also provide a copy of your C.V.
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5.DeclarationI confirm that the information given on this form is complete and correct to the best of my knowledge. I have also read the information pack and can confirm that I am eligible to be considered for appointment to the Civil Service Board of the Welsh Government. I also certify that I will immediately inform the Welsh Government of any changes in circumstances that affect the answers I have given.
Signed:
Name in BLOCK LETTERS:
Date:
Please return this form:
by email to: s
or by post to:
Senior Civil Service Team
2nd Floor East CP2
Welsh Government
Cathays Park
Cardiff
CF10 3NQ
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6.Political ActivityAll applicants for a public appointment should complete the question below. This question is asked as it enables the monitoring of political activity of candidates for a public appointment in so far as it is already in the public domain. Neither activity nor affiliation is a criterion for appointment (except where statute dictates specific representation). If you are successful, the information provided will be published with the announcement of your appointment.
Please indicate which of the following activities you have undertaken during the past five years by ticking the appropriate box and by providing details of your involvement. Name the party or body for which you have been active. If you have been or are an Independent or have sought or obtained office as a representative of a particular interest group, you should state this. You should tick all relevant categories.
a. / Obtained office as an Assembly Member, a Local Councillor, MP, MEP, etc
Stood as a candidate for one of the above offices
Spoken on behalf of a party or candidate
b. / Acted as a political agent
Held office such as Chair, Treasurer or Secretary of a local branch of a Party
Canvassed on behalf of a party or helped at elections
Undertaken any other political activity which you consider relevant
c. / Made a recordable donation to a political party 1
d. / None of the above activities apply
Details of involvement:
Name of Party for which activity undertaken:
Signed
Name in BLOCK LETTERS
Date
1 The Political Parties, Election and Referendums Act 2000 requires the Electoral Commission to publish a register of recordable donations (donations from any individual totalling more than £5000 in any calendar year, or more than £1000 if made to a subsidiary accounting unit such as a constituency association, local branch, women’s or youth organisation). These provisions became effective from 16 February 2001
Equal Opportunities
Welsh Government Equal Opportunities Statement
The Welsh Government is committed to recruiting, retaining and developing a workforce that reflects the diverse communities that we serve. It is vital that we monitor and analyse diversity information so that we can ensure that our employment practices are fair and transparent, and promote equality of opportunity. Your cooperation in providing us with accurate data will help us to meet our legal obligations set out under the Equality Act 2010. Any information provided on this form will be treated as strictly confidential and will not be used in any way which allows any individual to be identified.
This information is collected for monitoring purposes only and is not seen by the selection panel.
Q. Gender * Male / Female / Prefer not to say (delete as appropriate or enter below)
Q. Is your gender identity the same as the gender you were born with? * Yes / No / Prefer not to say (delete as appropriate or enter below)
Q. Are you married or in a civil partnership? * Yes / No / Prefer not to say (delete as appropriate or enter below)
Q. Are you currently pregnant or have you been pregnant in the last year? * Yes / No / Prefer not to say (delete as appropriate or enter below)
Q. Have you taken maternity leave within the past year? * Yes / No / Prefer not to say (delete as appropriate or enter below)
Q. Age range * (Insert an X next to the relevant selection)16-24 / 25-29
30-34 / 35-39
40-44 / 45-49
50-54 / 55-59
60-64 / 65+
Prefer not to say
Q. How would you describe your national identity?*
British or Mixed British / English
Northern Irish / Scottish
Welsh / Other national identity
Prefer not to say
Q. What is your ethnicity?*
White - Gypsy or Irish Traveller / Mixed,multiple ethnic groups - White and Asian
White - Irish / Mixed,multiple ethnic groups - White and Black African
White - Welsh, English, Scottish, Northern Irish, British / Mixed,multiple ethnic groups - White and Black Caribbean
White - Other white background / Mixed,multiple ethnic groups - Any other mixed background
Asian,Asian British / Black,African,Caribbean
Asian,Asian British - Bangladeshi / Black,African,Caribbean - Black - African
Asian,Asian British - Chinese / Black,African,Caribbean - Black - Caribbean
Asian,Asian British - Indian / Black,African,Caribbean - Any other Black background
Asian,Asian British - Pakistani / Other ethnic group - Arab
Asian,Asian British - Any other Asian background / Other ethnic group - Any other ethnic group
Prefer not to say
Q. What is your sexual orientation?*
Bisexual / Heterosexual, straight
Gay man / Other
Gay woman, lesbian / Prefer not to say
Q. What is your religion or belief?*
Agnostic / Paganism
Atheist / Rastafarian
Baha’i / Shinto
Buddhist / Sikh
Christian / Tao
Hindu / Zoroastrian
Humanism / Other religion
Jainism / No religion
Jewish / Prefer not to say
Muslim
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