Portage Home Visitor – Application Form

Personal Information

Surname / Forenames
Title / Date of Birth
Home Address / Daytime Telephone Number
Evening Telephone
Number / Mobile Telephone Number
E-mail Address

Qualifications & Training(Please continue onto a separate sheet if necessary)

Qualification/Grade Obtained

/ Date (most recent first)
Qualification/Grade Obtained Continued / Date (most recent first)

Experience

Please give details of your working experience starting with your present or most recent employer and working backwards. If you have been out of work for sometime please use this space to describe how you have gained experience relevant to your application.Please continue onto a separate sheet if necessary.

Name and Address of Employer

/ Dates from / to
(most recent first) / Job Title & Main Duties

Supporting Statement

Please make full use of this section to give further information in support of your application.

(You may wish to continue on a separate sheet, maximum please of two sides of A4 paper.)

Additional Information

Do you have regular access to the use of a car? / Yes / No
What date would you be available to start?

References

Please give names & addresses of two people whom we may contact for a reference. One of these should be your present or most recent employer.

The other must be known to you for at least two years.

Current / Most recent Employer / Other (not a family member)
Name / Name
Address / Address
Telephone / Telephone
Relationship / Relationship
May we can we take up these references prior to interview? Yes / No. / May we can we take up these references prior to interview? Yes / No.

Please Note

The post for which you are applying gives access to children. You should note that if your application is successful you will be required to obtain an ‘Enhanced Disclosure’ from the Criminal Records Bureau. Employment will be conditional upon the results of the ‘Enhanced Disclosure’ obtained, which will indicate your suitability to work within the team.

Deliberate omission or falsification of information could lead to disqualification of your application or later dismissal if appointed.

Data Protection Statement – Data Protection Act 1998

Wiltshire Portage has a duty to protect personal information. Wiltshire Portage will process this information in accordance with the Data Protection Act 1998. This information will be stored on computer and manual files.

Declaration

I certify that the information in this application is accurate and complete to the best of my knowledge.

Signature of Applicant: / Date:

Please return to:

Cathy Welch–Wiltshire Portage, Kings Rise Children’s Centre,

Pewsham, Chippenham, Wiltshire. SN15 3SY

Or e-mail

By Friday 24th November at Noon.

Candidate Number (internal use only)

Page 1 of 6