APPLICATION FORM
Position: / Mental Health Service Coordinator / Ref (office use only)EXPERIENCE:
Please look at the job description and personal specification for the post and then use this section to outline what qualities, skills and experience you would bring to this post. Ensure that you address all areas of the personal specification.
Please make sure that you illustrate, from your previous experience, any of the points that you wish to bring the attention of the short listing panel. “Experience” can be from a work, voluntary, or personal capacity.
Please continue on separate sheets as needed
WORK HISTORY:
Present or most recent employment:
Name and address of Employer:
Position held:
Date appointed: / Date left:
Current or most recent salary:
Brief description of duties and responsibilities:
Previous employment:
Please list your previous history including any casual or part time work and regular voluntary work, starting with the most recent (add more rows as necessary).
Name and address of Employer: / Date from: / Date to: / Position held: / Brief description of duties and responsibilities:
Voluntary work history (add more rows as necessary):
Name and address of Employer: / Date from: / Date to: / Nature of voluntary work:
In order to enable the Settlement to comply with safer recruitment practices, please explain any gaps in your employment history (add more rows as necessary):
Period of gap: / Reason:
EDUCATION AND TRAINING:
Please give details of any courses, training, education and qualifications that will support your application (add more rows as necessary).
Secondary Education:
Name of institute: / Location: / Dates attended: / Qualifications gained:
College, University or Vocational Training:
Name of institute: / Location: / Dates attended: / Qualifications gained:
Short work related or personal interest courses:
Course title: / Dates/length of course: / Name of organisation: / Qualifications gained:
OTHER INFORMATION:
If there are any factors not already been covered which you would like the selection panel to be aware of please give details:
If you have a disability, please give details of how we can make it easier for you to attend an interview if you are shortlisted:
Do you have a full, current driving licence?
If offered this post, when would you be available to start?
The following pages will be removed from the application form for the short listing process.
PERSONAL DETAILS:
Surname: / First name:
Address: / Day time tel no.:
Evening tel no.
e-mail: / Date of Birth:
REFERENCES:
Please give details of two referees. One referee must be your present or most recent employer.
If you are applying for a post that involves working with children and/or vulnerable adults, and your most recent employment does not involve working with these groups, you must provide a referee for paid or unpaid work where you have worked with one or either of these vulnerable groups.
References will only be taken up if you are offered the post.
Reference 1:
Name: / Address:
Position:
Organisation:
Tel no: / e-mail:
Reference 2:
Name: / Address:
Position:
Organisation:
Tel no: / e-mail:
REHABILITATION OF OFFENDERS ACT - This must be completed and returned with the application form:
This post is exempt from the requirements of the Rehabilitation of Offenders Act 1974 because it involves working with children and/or vulnerable adults. This means that you are obliged to disclose the details of any offence that resulted in a criminal conviction, even if it was a long time ago.
If this applies to you, please enclose in a sealed envelope marked ‘CONFIDENTIAL and with your name’ the details of the offence, date, sentence and any comments you wish to make. If not appointed the envelope will be returned.
Please tick below as appropriate:
I have no convictions:
Envelope attached:
DECLARATION - This must be completed and returned with the application form:
I confirm that the information I have given on this form is correct and complete and that misleading statements may be sufficient for cancelling any agreements made. Because of the sensitive nature of the duties the post holder will be expected to undertake, I understand that the declaration will include details of any criminal convictions, both spent and unspent, cautions, reprimands and final warnings and any other information that may have a bearing on my suitability for the post. I understand that an Enhanced Criminal Records Disclosure will be sought in the event of a successful application.
Signature: / Date:
Print name:
DATA PROTECTION STATEMENT:
All the data on this form is confidential, and will be seen only by the selection panel and the administrator. It will not be used for any other purpose other than the application.
Forms from unsuccessful applicants will be held for six months. If a similar job vacancy occurs within that time, we may send you another application pack.
If you do not wish us to do this, please tick here:
After six months, forms from unsuccessful applicants and all other documentation relating to the application will be destroyed.
Blackfriars Settlement Application Monitoring Form
To assist Blackfriars Settlement in implementing the organisation’s equalities and diversity policy please complete the following. The information you provide is confidential and will not be used in the selection process. After recruitment is complete the information will be collated into numerical form for monitoring purposes.
Please indicate:
1 / Your gender, including gender identity:
2 / Your ethnic Origin: Please tick the box which best describes you.
White British / Asian or Asian British- Indian
White Irish / Asian or Asian British- Pakistani
White Other / Asian or Asian British- Bangladeshi
Mixed White & Black Caribbean / Asian or Asian British- Other
Mixed White & Black African / Black or Black British- Caribbean
Mixed White & Asian / Black or Black British- African
Mixed Other / Black or Black British- Other
Other / Chinese
No Response
3 / Your age:
4 / Your sexual orientation:
5 / Your religion or beliefs:
6 / Do you consider yourself disabled? / yes / no
7 / Where did you see this job advertised?
(if it was a newspaper, please state which one)