/ Application form

Please complete this form as fully and carefully and return it by post/email. Please relate your application to the job details, which have been provided. Applications will only be considered from candidates who meet the essential criteria outlined in the person specification.

The information given on this page is to help us develop and monitor our equal opportunities policy and will not be used in the selection process.

Position applied for

/ Carer Wellbeing Facilitator ( BME Communities)

How did you find out about this post?

Title

/ Mr / Mrs / Ms / Miss / Forename(s)

Surname

Address /

National Insurance Number

May we call you at work? / YES / NO

Work Telephone No.

Email address:

Postcode

/

Preferred Contact Telephone No.

Ethnic Origin (please tick which you feel best describes your ethnic origin)
Bangladeshi / ¨ / Black/Other / ¨ / Pakistani / ¨
Black/African / ¨ / Chinese / ¨ / White / ¨
Black/Caribbean / ¨ / Indian / ¨ / Other (please state)

Gender

/ Male / ¨ / Female / ¨
Do you have a disability you would like us to know about?
If yes, what is the nature of your disability? /

YES / NO

Are you registered disabled? /

YES / NO

Do you have any particular requirements regarding the interview?
If yes, please give details /

YES / NO

Are you an unpaid Carer ? /

YES / NO

Rehabilitation of Offenders Act 1974
This post is exempt from the Act (under which some offences are deemed ‘spent’ after a certain time) and applicants are required to declare all past convictions.
Have you ever been convicted of a criminal offence?
If yes, please give details /

YES / NO

Declaration - I declare that the information on this form is true and correct and can be treated as part of any subsequent contract of employment
Signature / Date
JOB APPLICATION FORM -Carer Wellbeing Fecilitator / Page 4/ 5
/ Application form

Job Title

/

Carer Wellbeing Facilitator ( Benefits)

Employment History (continue on a separate sheet if necessary)

Present or last employer’s name and address / Job title
Grade and salary
Date commenced
Notice required or date left
Reason for leaving
Brief description of duties and responsibilities
Previous Employment (most recent first – please explain gaps and include any voluntary work)
Employer’s name and address / Position and main duties of post / Salary / Dates
Education, Training and Qualifications
Secondary school / Subject / Qualifications (include grades or class)
College/university / Subject / Qualifications (include grades or class)

Work Related Training

Organising body / Course title/subject / Duration / Dates
Membership of professional bodies/professional qualifications
Name of body/qualification / Class/grade of membership / Date obtained

Leisure Activities

Please give details of leisure activities, hobbies, etc
Additional Information (continue on a separate sheet if necessary)
Please state briefly why you think you would be suitable for this job. Give details of skills, knowledge and experience relevant to the job (see person specification) gained either in previous jobs or from activities outside employment.

General Information

Do you hold a driving licence /

YES / NO

Does it carry any endorsements?

If yes, please give details

/

YES / NO

Do you have a car that could be used for work, if required? /

YES / NO

How many days’ sick have you had in the past 18 months?

Please give details

References

Please give the name and addresses of two referees, one of whom should be your current or most recent employer. If you are in, or have just completed, full-time education, one referee should be from your school, college or university. Relatives cannot be used as referees.
We may contact your referees prior to interview. Please tick the small box if we should not approach a referee until after interview.¨
1.  / Name
Address
Tel number
Email address:
Position held / 2.  / Name
Address
Tel number
Email address
Position held

Please return your completed form (preferably by email) to:

To Brian Pereira

Gateshead Carers Association

John Haswell House

8-9 Gladstone Terrace

Gateshead NE8 1LU

Tel: 0191 4900121

Fax: 0191 4900128

Email:

JOB APPLICATION FORM -Carer Wellbeing Fecilitator / Page 4/ 5