The Appointment of Chairs and Non-Executive Members of Primary Care Trusts

Personal Information Form–SSAC Committee Member

Please complete on your own PC and returned by email to . If completing by hand, please use black ink to assist with photocopying. This form must be returned to the Department of Work and Pensions with your CV and accompanying letter which should set out how you meet the criteria for the role.

Part 1: Your personal details

Surname
Forenames
Title
Honours
Home address
Postcode
Home contacts / Phone / Mobile
Email

Business address

(if applicable)
Postcode
Work contacts / Phone / Mobile
(if applicable) / Fax / Email

Which address would you prefer Home Address Business Address

we use for correspondence?

Preferred e-mail address
Your current job title

Part 2: How you found out about these posts

Please as appropriate

Public Appointments Website / Which one
From the cabinet office
From the (SACC) Website
From the DWP
Word of mouth
LinkedIn
Other Website e.g NEDonBoard, / Please give details
WomenonBoards
Other

Part3: Declaration of interests

Do you have any business or personal interests that might be relevant to the work of the SSAC and which could lead to a real or perceived conflict of interests were you to be appointed? (Failure to disclose such information could result in an appointment being terminated.)

No / Yes

If yes, please give details below:

Part 4: References

Please give details of two referees, at least one of whom must be related to your recent professional activity. They will not be approached unless you are invited to interview. An appointment will not be offered until we have received satisfactory references.

Name

Address

Postcode

Tel No

Tel no

E-mail

How do you know him / her?

No / Yes

May we contact them before interview?

Part 5: Future contact

If you are unsuccessful in this application, may we keep your contact details on our records to inform you of other public appointments for which we think you might be a suitable candidate?
Yes

Monitoring Information

Most of the information requested in this form including in Parts 6-14below is not seen by the panel assessing your application (though the panel may consider your declaration of interests in Part 3).

Your name:Your postcode:

Part 6 – Age

66+
56-65
46-55
36-45
35 & under

Part 7 – Gender

Male / Female

Part 8 – Ethnic Origin

White / Black or Black British / Asian or Asian British / Chinese and other / Mixed
British / African / Bangladeshi / Chinese / Asian & white
Irish / Caribbean / Indian / Any other ethnic background / Black African & white
Any other white background / Any other black background / Pakistani
Black Caribbean & white
Any other Asian background
Any other mixed background

Part 9– Disability

No / Yes

Do you have any long-term illness, health problem or disability which may affect your daily activities or the work you can do?”

If “Yes”, it would be helpful if you could let us know how we could adapt the working environment to meet your needs and/ or what other assistance we could provide to help you.

Part 10 – Political activity question

All 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 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.

Obtained office as a Local Councillor, MP, MEP, etc.
Stood as a candidate for one of the above offices
Spoken on behalf of a party or candidate
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
Made a recordable donation to a political party[1]

Name of Party for which activity undertaken:

Details of involvement:

None of the above activities apply

Part 11: How would you characterise your previous career profile:

Mainly Civil Service
Mainly Private Sector
Mainly wider public sector
Mainly third sector

Part 12: Ministerial appointments currently held

Is this your first ministerial appointment?

No / Yes

Do you hold any other Ministerial appointments made by or on behalf of Ministers?

No / Yes

If "yes" please give the following additional information

Body / Period of appointment / Payments received / Government
Department
From / To

Part 13: Publication of monitoring information

Information on the composition of public bodies is published. The Cabinet Office may need information on ethnic origin and disability in response to Parliamentary Questions and other public enquiries and the Data Protection Act requires that those providing this information must be informed and their consent given, even though individuals are not identified.

Do you consent, therefore, to this information being made publicly available?

No / Yes

Part 14: Declaration

I confirm that to the best of my knowledge and belief, the information given in this form is complete and correct. I further confirm that I have considered and understood the criteria for disqualification from appointment and that I do not fall within any of the descriptions of persons specified in those criteria. I understand that if I am appointed and the information I have provided is subsequently found to be untrue then my tenure of office may be terminated. I also confirm that I have read and I am fully aware of the standards of probity required by public appointees as outlined in the Code of Practice in Appendix 4).

Please note if you are submitting your application by email we do not require a hard copy in the post. A signature will only be required if you are appointed.

Signature / Date
Please return completed forms to:
Email:
Alternatively, please post to:
Carmela Keogh
ALB Public Appointment Team
Department for Work and Pensions
Private Pensions and Stewardship
1st Floor, Caxton House
Tothill Street
SW1H 9NA

[1]The Political Parties, Elections 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.