National Examining Board for Dental Nurses

Application form to be a Trustee of NEBDN

Important – please read this before completing the application form

NEBDN wishes to ensure that comparison between applicants for posts is thorough, fair and in line with our equal opportunities policy. It is therefore essential that you complete this application form fully as it will be used to assess whether or not you are shortlisted for interview.

You are advised to read fully the supporting guidance for the post before completing the form.

CVs will only be accepted to support completed application forms.

Please print in black ink or type when completing this form.

When you have completed the form, please send it – marked “Private & Confidential” - to

Laura Oddie, Executive Assistant to the Chief Executive,

NEBDN, First Floor, Quayside Court,

Chain Caul Way,

Preston,

Lancashire,

PR2 2ZP

or by e-mail to

Your application must be received before 5.00pm on Friday 7 April 2017 otherwise we cannot consider it.

Part 1: Your personal details

Surname
Forenames
Title
Home Address
Business Address
Home contacts / Phone: / Mobile:
Fax / Email:
Business contacts / Phone: / Mobile:
Fax / Email:

What is the best way to contact you?

Home address / Business address / Email: Home
Business / Phone:
Home
Business / Mobile:
Home
Business

Part 2: References

One reference should be a business/professional contact.

Name / Name
Address / Address
Postcode / Postcode
Telephone / Telephone
Email / Email
How do you know this person? (e.g. business, personal, etc.) / How do you know this person? (e.g. business, personal, etc.)
May we contact prior to interview? / Yes/no* / May we contact prior to interview? / Yes/no*

* Please delete as appropriate

Part 3: Personal assessment (see guidance notes)

Please indicate below how you meet the essential areas in the person specification. We will use your answers to judge whether or not you have the qualities for the post as set out in the application pack. You should provide examples that demonstrate that you have the required qualities.

Area 1 - Commitment
Area 2 - Focus
Area 3 – Communication and team working
Area 4 – Accountability
Area 5 – Management
Area 6 – Stewardship and governance
Area 7 – Specialist expertise

Part 4: Declaration of interests (see guidance notes)

Do you have any business or personal interests that might be relevant to the work of the National Examining Board for Dental Nurses and which could lead to a real or perceived conflict of interests were you to be appointed? (Failure to disclose such information could result in any appointment being terminated).

No / Yes

If yes, please give details:


Part 5: Declaration

I confirm that, to the best of my knowledge and belief, the information given in this form is complete and correct. I further confirm that I have considered and understood the criteria for appointment and that I fall within the description of persons specified in those criteria.

I understand that if I am appointed and the information I have provided is subsequently found to be untrue then my appointment may be terminated.

Please note: if you are submitting an application form by email we do not require a hard copy in the post. A signature will only be required if you are appointed.

Signature / Date

Closing date for applications: 5pm on Friday 7 April 2017

Completion of this form is entirely voluntary and is not a requirement of application.

The NEBDN is committed to promoting and developing equality and diversity in all our work. We want to be as sure as we can that our policies and ways of working are fair and do not discriminate against individuals or groups. To help us monitor the effectiveness of our policies and practices we ask you to complete this diversity questionnaire. This information will be treated in the strictest confidence under the Data Protection Act 1998. We will use it to check our policies and processes promote equality and to address any issues that arise. This form will be detached from your personal information and securely destroyed.

1. Ethnic origin

Tick ONE of the boxes below that best represents your cultural background

Asian:
☐ Bangladeshi
☐ Indian
☐ Pakistani
☐ Other (please specify in box) / Mixed Ethnic:
☐ Asian & White
☐ Black African & White
☐ Black Caribbean & White
☐ Other (please specify)
Black:
☐ African
☐ Caribbean
☐ Other (please specify) / White:
☐ White
☐ Irish
☐ Other (Please specify)
Chinese:
☐ Chinese
☐ Other (please specify) / ☐ Any other ethnic background:
(please specify):
☐ Prefer not to say

2. Disability

Do you consider yourself to have a disability?

The Equality Act 2010 defines disability as a physical or mental impairment which has substantial long-term effect on a person’s ability to carry out normal day to day activities

☐ Yes ☐ No ☐ Prefer not to say

3. Gender identity

Is your gender identity the same as the gender you were assigned at birth?

☐ Yes ☐ No ☐ Prefer not to say

Do you live and work full time in the gender role opposite to that assigned at birth?

☐ Yes ☐ No ☐ Prefer not to say

Do you feel able to discuss your gender identity with colleagues at work?

☐ Yes ☐ No ☐ Prefer not to say

4 Religion/ belief

Tick ONE of the boxes below that represents your religion/ beliefs

☐ Buddhist / ☐ Christian / ☐ Hindu / ☐ Jewish
☐ Muslim / ☐ Sikh / ☐ None / ☐ Prefer not to say
☐ Other religion/ belief (Please specify):

5 Sexual orientation

Tick ONE of the boxes below that represents your sexual orientation

☐ Bisexual / ☐ Gay man / ☐ Gay woman / ☐ Heterosexual / ☐ Prefer not to say

Thank you for completing the questionnaire

Trustee Application Form 2017 Page 1 of 10