EQUAL OPPORTUNITIES MONITORING FORM /

Adoption Matters is an Equal Opportunities employer and is committed to ensuring equality of opportunity to all those who have contact with the organisation. To help ensure that our Equal Opportunities Policy is working effectively, we would be grateful if you could complete this form. The information on this page will only be used for statistical monitoring and will not affect the pre-selection of candidates. It will be detached prior to screening and selection for interview.

Gender: / Male / / Female / / Do you identify as transgender
(an individual who wants to change their gender
to the opposite of that they were assigned at birth?) /
Prefer not to say

Date of Birth:
ETHNIC ORIGIN:
White: / White British / Asian or Asian British: / Indian
White Irish / Pakistani
Other white background / Bangladeshi
Mixed: / White and Black Caribbean / Other Asian background
White and Black African / Black or Black British: / Black Caribbean
White and Asian / Black African
Other mixed background / Other black background
Chinese or other ethnic group: / Chinese
Prefer not to say / Other ethnic background

DISABILITY:

The Equality Act 2010 seeks to protect the employment rights of people with disabilities. The Act defines a disability as any physical or mental impairment, which has a substantial or long term adverse effect on the ability to carry out normal day to day activities.

Do you consider yourself to have a long term medical condition that may require adjustments to be made to the working environment?

Yes No Prefer not to say

Please list any reasonable adjustments you think you may require:

______

______

How did you find out about this post?

Job Centre / Internal advert
Personal recommendation / Adoption Matters website
Local Newspaper – please specify: / Other website – please specify:

Do you have any previous association with this Agency? Yes No

If Yes, in what capacity?......

Data Protection

For the purposes of compliance with the Data Protection Act 1998, I hereby confirm that by completing this form I give my consent to the Company to process the data supplied on this form for the purpose of monitoring its Equal Opportunities Policy, and for statistical purposes.

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JOB APPLICATION FORM
CONFIDENTIAL /

Important: This information will be used as the basis of pre-selection of applications and at any future selection process. Please complete all sections of the form in full.

Please email the completed form to or post to: The Human Resources Department, Adoption Matters, 14 Liverpool Road, Chester, Cheshire, CH2 1AE

POSITION APPLIED FOR:

PERSONAL DETAILS:

SURNAME: / FIRST NAME/S:
ADDRESS:
POST CODE: / MOBILE:
TEL NO – HOME: / E-MAIL:
TEL NO – WORK: / NI NO:
PREFERRED TITLE: / HCPC REG NO
(Social work posts only)
Would you require a work permit to take up this appointment? / YES / NO
(UK and EEA citizens do not require work permits)

OTHER DETAILS

The amendments to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are 'protected' and are not subject to disclosure to employers; and cannot be taken into account. Guidance and criteria on the filtering of these cautions and convictions can be found on the DBS website https://www.gov.uk/government/news/disclosure-and-barring-service-filtering
Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198? If yes, please give details. Yes/No
Do you hold a current driving licence? Yes/No
Are there any dates when you would not be available for interview? If yes, please give details. Yes/No
PLEASE COMPLETE SECTIONS 1 TO 6 AS FULLY AS POSSIBLE

PRESENT OR MOST RECENT EMPLOYMENT - SECTION 1

DATES / JOB TITLE / EMPLOYER’S NAME, LOCATION & NATURE OF BUSINESS / RENUMERATION /
BENEFITS
FROM
Mm/yyyy / TO
mm/yyyy
BASIC:
OTHER:
Summarise main responsibilities and achievements:
Notice required: / Reason for leaving:


EMPLOYMENT HISTORY - SECTION 2

Please give details of all appointments you have held prior to your present post, starting with the most recent.

DATES / POSITION HELD / EMPLOYER’S NAME, LOCATION & NATURE OF BUSINESS / MAIN RESPONSIBILITIES & ACHIEVEMENTS / REASON FOR
LEAVING
FROM
mm/yyyy / TO
mm/yyyy
EDUCATION & TRAINING - SECTION 3
Starting with the most recent first.
DATES / NAME OF UNIVERSITY/COLLEGE/SCHOOL / QUALIFICATIONS & GRADE OBTAINED / MAIN SUBJECTS STUDIED
Membership of Professional Institutions:

You will be asked to produce appropriate certificates at interview.


COURSES ATTENDED - SECTION 4

DATES / NAME OF TRAINING ORGANISATION / NAME OF COURSE & DATE ATTENDED / MAIN SUBJECTS STUDIED
COMMENT - SECTION 5

Please explain why you are applying for this position using examples to show how you meet the requirements of the Person Specification.

REFERENCES – SECTION 6

Please give the names, addresses and telephone numbers of two referees who would be prepared to comment on your professional ability. One of these should ideally be your current line manager – if you are unable to provide this individual’s details please specify why and provide an alternative work related referee. Referees will NOT be approached before you have been offered an appointment. Telephone verification of written references will be made.

1.  Current Line Manager / 2.
Tel No:
E-mail:
If the above referee is not your current line manager please specify why and in what work related capacity does this referee know you? / Tel No:
E-mail:
In what capacity does this referee know you? (eg employer, line manager, friend etc?)

All posts are subject to an Enhanced DBS check.

REASONABLE ADJUSTMENTS

Reasonable adjustments support is available to candidates with disabilities when applying for vacancies. If you would like more information please indicate below and we will contact you.

DECLARATION

I confirm that, to the best of my knowledge, the information given on this form is correct.
I agree to an Enhanced Disclosure & Barring check being undertaken if my application for this post is successful.
Data Protection: I agree to Adoption Matters using personal data contained in this form, or other data which Adoption Matters may obtain from me or other sources, for the purpose of dealing with my application for employment.
Signature / Date

Thank you for completing the form.

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