ROLE APPLYING FOR: Trustee / Treasurer / Chair

(delete as appropriate)

TITLE
FULL NAME
ADDRESS
POSTCODE
EMAIL
HOME No.
MOBILE No.

MOTIVATION

Please tell us why you wish to become a Ashford Place Trustee and why you believe you will be an effective Ashford Place Board Member

CURRENT SITUATION

What is your current employment situation?(delete as appropriate)

In full-time employment / In part-time employment / Retired / Unemployed / Other

If in employment, please give details of current role

Job Title
Employer
Start Date
Please give details of duties performed, responsibilities, skills used or learned, advancements, whilst you have worked for this organisation

PREVIOUS EMPLOYMENT

Please outline your employment history and achievements (a C.V. should be submitted with your application)

SKILLS

Please indicate which of these specialist skills you believe you possess and at which level you consider your knowledge/experience

Expert / Some / Little/None
Alcohol & drug services
Financial management
Fundraising
Governance
Homelessness services
Legal services
Local government
PR/Marketing
Risk management
Strategic planning
Training/employment
Please give details of education and qualifications held, along with membership of any professional bodies that you think relevant to your application as a Ashford Place Trustee
Please give details of any current or previous board level experience
Please give details of any other skills, experience or knowledge you have which may add value to Ashford Place, and, how you would implement your ideas at board level

REFERENCES

Please give details of 2 referees. References will only be taken up for the successful candidate. Testimonials or references from friends are not acceptable

Name
Position
Organisation
Address
Postcode
Email
Relationship to you
Contact number

DECLARATION OF ELIGIBILITY

I declare that I am not disqualified from acting as a charity trustee and that:


I am not incapable of acting by reason of mental disorder within the meaning of the Mental Health Act 1983
I do not have any unspent conviction relating to any offence involving deception or dishonesty
I am not an undischarged bankrupt nor have I made a composition or arrangement with, or granted a trust deed for, my creditors
I am subject to a disqualification order under the Company Directors Disqualification Act 1986 or to an order made under section 429(b) of the Insolvency Act 1986
I have not been removed from the office of charity trustee or trustee for a charity by an order made by the Charity Commissioners or the high court on the grounds of any misconduct or mismanagement. Nor am I subject to an order under section 7 of the Law Reform (Miscellaneous Provisions) (Scotland) Act 1990, preventing me from being concerned in the management or control of any relevant organisation or body
I am not subject to a disqualification order under the Criminal Justice and Court Services Act 2000
I am not disqualified under the Protection of Vulnerable Adults List

DATA PROTECTION STATEMENT

In accordance with the Data Protection Act 1998, the information provided on this form will be used in the recruitment and selection process and may be disclosed to all who see it. Checks will be made on information provided. This information will also form the basis of the confidential personnel record of the successful candidate. In the case of unsuccessful candidates, the information will be destroyed after 12 months. In addition it will be held on a database and used for equal opportunities monitoring purposes.

I hereby apply for the role of Ashford Place trustee. I declare that the information I have submitted on this form is true to the best of my knowledge. I agree that my information can be used and kept in line with the data protection statement.

Signature
Print Name
Date

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