Appendix A

PEMBROKESHIRE COUNTY COUNCIL

APPLICATION FOR THE ROLE INDEPENDENT

MEMBER OF THE STANDARDS COMMITTEE

Please note that each section MUST be completed.

1.  YOUR DETAILS
Your full name:
Your address and postcode
Contact telephone numbers(s)
Email address
2.  ELIGIBILITY
a)  Are you a Member or Officer of any County, County Borough, Town or Community Council, Fire Authority or National Park Authority in Wales? / Yes
o / No
o
b)  In the last twelve months have you been a Member or Officer of any County, County borough, Town or Community Council, Fire Authority or National Park Authority in Wales? / Yes
o / No
o
c)  Is your spouse a Member or Officer of any County, County Borough, Town or Community Council, Fire Authority or National Park Authority in Wales? / Yes
o / No
o
d)  In the last twelve months has your spouse/civil partner been a Member of Officer of any County, County borough, Town or Community Council, Fire Authority or National Park Authority in Wales? / Yes
o / No
o
e)  Were you at any time a Member or Officer of Pembrokeshire County Council? / Yes
o / No
o
3.  PRESENT EMPLOYMENT
4.  PREVIOUS EMPLOYMENT
Name of Employer / From / To / Post Held
5.  EDUCATIONAL QUALIFICATIONS
From / To / School/College/University etc / Qualifications
6.  MEMBERSHIP OF PROFESSIONAL BODIES
Name of Professional Body / Membership Status
7.  CRIMINAL OFFENCES
Have you ever been convicted of a criminal offence or received a police caution? Yes o No o
If yes please provide details:
8.  PLEASE EXPLAIN HOW YOU MEET THE CRITERIA FOR THIS ROLE BY REFERENCE TO RELEVANT EXPERIENCE AND WHY YOU WISH TO BECOME AN INDEPENDENT MEMBER OF THE STANDARDS COMMITTEE
9.  PLEASE GIVE DETAILS OF ANY SPARE TIME OR RECREATIONAL INTERESTS AND ACTIVITIES, MEMBERSHIP OF ORGANISATIONS AND CLUBS, VOLUNTARY WORK ETC WHICH YOU FEEL WOULD BE RELEVANT TO THE WORK OF THE STANDARDS COMMITTEE
10.  REFERENCES

Please provide details of two people who can be contacted to give a character reference in support of your application. Referees will be contacted upon receipt of your application. You should not approach any Pembrokeshire County, Town or Community Member or Co-opted Member or Council Officer nor their spouses or partners to be a referee.

Referee One / Referee Two
Full Name
Address and postcode
Contact telephone number(s)
E-mail address
Occupation
11.  DECLARATIONS
Please declare Membership of any Private Clubs, Societies or Associations of which you are a Member

I hereby declare that I wish to apply for the role of Independent Member of the Standards Committee and that I meet the eligibility criteria set out in the information booklet.

Signed : Date :

Please return this form by post or email to Jenny Capitao

, Committee Services, Pembrokeshire County Council, County Hall, Haverfordwest,

SA61 1TP, by 10 June 2018