DISCLOSURE OF CRIMINAL RECORD

Please complete in BLOCK CAPITALS and return in the envelope provided.

Please  appropriate box / delete inapplicable alternatives where appropriate.

REHABILITATION OF OFFENDERS ACT 1974 (EXCEPTION) (AMENDMENT) ORDER 1986

Owing to the nature of the work, this post is excepted under the Exemptions Order (S1 1986 No. 1249) of the Rehabilitation of Offenders Act 1974.
As such, you are required to declare details of all / any spent and unspent past court convictions, bindovers and cautions, and any judgements or investigations pending, in order to determine your suitability for appointment to this post.
Should you be offered the post, this offer will be subject to the Authority being satisfied as to your suitability, following a check on any record of convictions, bindovers or cautions with the Criminal Records Bureau, (together with any other additional recruitment checks).
In addition, you will be required to complete a Disclosure Application Form which will be sent to you following a (conditional) offer of appointment to this post.
Any information provided by the Criminal Records Bureau will not automatically result in the withdrawal of the offer, but will be taken into account in deciding whether the appointment should be confirmed.
This document and the information given in it, will be treated in the strictest confidence and will only be taken into consideration, if you are deemed appointable at interview.
Please ensure, that when completed, this form is sealed in the envelope provided and returned to the appropriate Officer.
Surname
Forename
Title / Date of Birth
Previous Name(s)
Position applied for / Role / Chaperone
Post No. (if applicable) / N/A
Business Unit / Establishment / Children’s Learning and Engagement
Directorate / Children’s Services

PLEASE COMPLETE OVERLEAF

Declaration (*Delete as appropriate)

I am aware that failure to declare any such convictions, bindovers and cautions, or any judgements or investigations pending may result in a formal offer of appointment not being made / the termination of my appointment in the above post, or any subsequent post.

ONE OF THESE ALTERNATIVES MUST BE DELETED.

PLEASE DELETE THE STATEMENT WHICH DOES NOT APPLY TO YOU.

*I have had no Court Convictions / bindovers / cautions nor are any judgements or investigations pending.

*I declare the convictions / bindovers / cautions / judgements pending / investigations stated below (please state nature of offence(s), decision of Court and approximate date).

Please continue on a separate sheet if there is insufficient space above.

I confirm that the information given is a true and accurate statement.

Signed / Date