WOMEN’S WORK AIMS TO BE AN EQUAL OPPORTUNITY EMPLOYER

Please complete this application in BLACK INK in BLOCK CAPITALS or in typewriting.

(Please complete the form in full. Do notsubmit a CV as part of this application)

Application for the post of: / Job Ref. No:
Organisation: Women’s Work(Derbyshire)Ltd / Closing date:

1.PERSONAL DETAILSNational Insurance No:

Title: / Surname: / First Names: / Have you a
Current Driving
Licence?
Address:
House Number:
Street Name:
Town:
County:
Are you eligible to work in the UK (proof will be required if offered post)
Postcode:
Telephone Numbers: Business / Work: / Home:
Mobile: / Ext: / E-mail:

2.EDUCATIONAL AND PROFESSIONAL QUALIFICATIONS

Qualifications obtained (please state all relevant qualifications and level attained) / Place of study / Grades / Date

3.MEMBERSHIP OF PROFESSIONAL BODIES

Professional Registering Body / Membership Status / Registration Number / Since

4.WORK HISTORY – CURRENT MOST RECENT POSITION

Employers Name and Address: / Nature of Business:
Present Grade/Salary/Wage:
Job Title (please give brief outline of your duties/responsibilities): / Other Benefits
Date of Appointment:
Notice Required:

5.PREVIOUS EMPLOYMENT - Starting with the most recent (Additional sheets may be attached if required).

Employer’s Name and Address / Position Held/Job Title / Dates
From To / Reasons for Leaving

Continue on a separate sheet if necessary

6.REFERENCES - Please give details of two referees - one of whom must be your present employer, or if unemployed your last employer, and one a previous employer (if possible). Other referees will only be acceptable in exceptional circumstances (e.g. if you have no previous employment you may give head teacher / lecturer)

A) Name
Position held by referee:
Organisation: (if appropriate)
Address
Telephone:
Email: / B) Name:
Position held by referee:
Organisation: (if appropriate):
Address:
Telephone:
Email:
NB If a provisional offer of employment is made; references WILL then be sought before the offer is confirmed.

7.RELATIVES - Please state below the name, designation and place of employment of any relative who is presently employed by, or is a member of, Women’s Work.

______

Failure to disclose this information can disqualify your application or, if appointed, render you liable to dismissal. Canvassing of officers or members of Women’s Work shall disqualify a candidate for appointment. This does not preclude a member or officer from giving a written testimonial of a candidate’s ability, experience or character.

8.FURTHER INFORMATION -Please provide information in support of your application, e.g. a brief description of your relevant experience, present duties, training and/or any other relevant information. Please attach additional sheets if necessary.

9.DECLARATION

I understand that any offer of employment will be subject to the information on this application (and CV if applicable) being complete and correct. Any false information or a failure to supply details required under Section 9 above, could make an offer of employment invalid or lead to termination of employment.
Signed
Date
Please complete and return this application form to:
Women’s Work( Derbyshire)Ltd
The Villa
30 Charnwood Street
Derby
DE1 2GU
Any telephone enquiries about this application should be made to: Telephone Number: 01332 242525

11.REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of Rehabilitation of Offenders Act (Exceptions) Order 1975 as amended. You are therefore required to disclose information about ALL cautions and/or convictions in a court of law, which for other purposes are considered as ‘spent’ under the Act.
Have you ever been cautioned and/or convicted in a court of law? Please put X in appropriate box YES NO
If you have any convictions you are required to supply details of these in a separate sealed envelope.
This information will be completely confidential and will only be considered in relation to an application for a post that the Order applies. In certain circumstances where posts involve substantial access to children and/or vulnerable adults, applicants will also be subject to a Disclosure and Barring Service ( DBS)

12.ASYLUM AND IMMIGRATION ACT 1996

Do you have evidence of your entitlement to live and work in the UK? YES NO
If your application is successful, you will be asked to produce this evidence.
(Please tick the box to confirm you will provide evidence).
Do you require a work permit? YES NO
Date of expiry of permit held

Disability Discrimination Act 1995

The Disability Discrimination Act protects people with disabilities from unlawful discrimination. If we know you have a disability we will make adjustments to your working arrangements or your working environment provided it is reasonable in the circumstances to do so.
Do you regard yourself as a disabled person? YES NO
If YES, are there any adjustments we should consider during the recruitment process (e.g. at interview), or the job itself, which might be helpful to you?

EQUAL OPPORTUNITIES MONITORING FORM

Women’s Work( Derbyshire)Ltd aims to be an Equal Opportunity employer. It is our policy to ensure that no job applicant or employee receives less favourable treatment on the grounds of marital status, sexual orientation, disability, colour, ethnic or national origins or is disadvantaged by conditions or requirements that cannot be shown justifiable. The organisation is committed to making this policy fully effective and to assist in monitoring this policy, and for that purpose only; you are requested to provide the following personal details by placing an “X” in the appropriate boxes. We will separate this part of the form from the application form. it will not form part of the selection process If you are in an ‘any other’ category or one not shown here, please describe in the spaces provided.

GENDER

Please tick one of the following boxes as appropriate
 Male
 Female  Prefer Not to Say

AGE

Date of Birth (dd/mm/yyyy)
 Prefer Not to Say

ETHNIC ORIGIN

Please tick one of the following boxes as appropriate
White / Black or Black British / Asian or Asian British / Dual Heritage / Chinese or other
 British /  Black Caribbean /  Indian /  White/Black Caribbean /  Chinese
 Irish /  Black African /  Pakistani /  White/Black African /  Other Ethnic
 Other White /  Other Black /  Bangladeshi /  White/Asian /  Not Stated
 Other Asian /  Other Mixed /  Prefer Not to Say
RELIGION
How would you describe your religion?
My faith is:
 I am not religious  Prefer Not to Say
NATIONALITY
How would you describe your nationality?
 British
 English
 Scottish
 Welsh
 Irish
 Other (please describe)
 Prefer Not to Say
DISABILITY
Do you consider yourself to be disabled? YES / NO
Do you have a disability as defined by the Disability Discrimination Act? YES / NO
 Prefer Not to Say

CONFIDENTIAL

PERSONAL BACKGROUND DISCLOSURE

The Women’s Work project works with vulnerable people. Under the terms of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975, you must disclose any convictions, including ‘spent convictions’. We have a written policy on recruitment of ex- offenders which is available on request. Women’s Work complies fully with the CRB Code of Practice and undertakes to treat all applicants for positions fairly. It undertakes not to discriminate unfairly against any subject of a Disclosure on the basis of a conviction or other information revealed.

  1. Do you have any Schedule One offences against children?

If yes please give details

  1. Do you have any convictions of violence, assault, fraud or robbery?

If yes please give details

  1. Do you have any convictions for drugs offences?

If yes please give details

  1. Have you had any social services investigations for concerns regarding

Child welfare?

If yes please give details

DECLARATION

I declare that the information I have given on this form is correct and complete to the best of my knowledge. I authorise Women’s Work to make any necessary enquiries to check the information on this form.

SignedDate

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