Application Form
Head Office: Clarence House
11 Clarence Road
Horsforth, LS18 4LB
t: 0113 3055800
Contact and Personal Details e:
w:www.leedsmind.org.uk
Post Applied for: …………………………………………………..
Where did you see the advert for this post?……………………………………
(if via the internet, please specify which website)
Contact & personal detailsPlease complete this sheet. It will be separated at the shortlisting stage to ensure complete anonymity of all applicants.
Surname: Forenames:
Address:
Postcode:
Telephone: Day: Evening:
Mobile: Email address:
Do you have use of a car? Yes / NO Do you hold a Current Driving license? Yes / No
Are you registered with the DBS on-line system? Yes / No
REFERENCES
Please give names and addresses of three referees- one of which must be your current employer, if applicable (indicate capacity in which you are known to them i.e. current employer, past employer) Referees should not be family members of personal friends.
Name: Job title:
Address:
Tel: Email:
Relationship to you:
Name: Job title:
Address:
Tel: Email:
Relationship to you:
Signature...... Date......
Post Applied for: ………………………………………………………
PRESENT OR MOST RECENT EMPLOYMENTName and address of present or last employer:
Tel. No. Can we contact you at work? YES/NO
Post Held: / Salary:
Date of appointment From: To:
Period of notice required:
Key responsibilities of the post:
WORK HISTORY
Please tell us about your work history, including any casual. part time or voluntary work. Do not leave any “gaps”, if you have spent time caring for dependants or travelling, please include this.
(this section can be expanded if required)
From / To / Employer’s name, address and nature of business / Post held and brief description of duties / Reason for leaving
EDUCATION, TRAINING AND QUALFICATIONS
Please give details of school, college, university, professional and vocational qualifications including current studies
Name of secondary school, college, university or other training bodies /
Dates
/Title of course / subject
/ Level / Result or GradeApart from through employment, have you acquired any experience or skills which you consider relevant to this post? (e.g. through voluntary or spare time work) [e.g. through voluntary work or spare time work].
Personal Statement to support your application for the postThe Person Specification lists the essential and desirable criteria necessary for this post, please demonstrate how you meet the requirements of this specification giving examples.
The statement must be a maximum of 2 A4 size pages long and use minimum font size 11.
Declarations
1. Are you connected to a business which trades with Leeds Mind YES/NO
If yes, please name the business and your involvement in it
………………………………………………………………………………………………………
2. Are you related to, or the partner of, a Leeds Mind Committee Member or employee? YES/NO
If yes, please name state name(s), relationship and if an employee, the post they hold
(It is not Leeds Mind’s policy to employ staff in a close relationship in the same project)
………………………………………………………………………………………………………
3. Leeds Mind is discharging a Social Service function and is covered by the Rehabilitation of Offenders Act 1974 [Exceptions Order 1975]. You are therefore obliged to disclose both current convictions and those which otherwise may be considered spent
4. Do you have any previous/current convictions? YES/NO
If so please give details below
DATE
/ NATURE OF SUMMONS/CHARGE / COURT / SENTENCE OR ORDERI understand that if I am offered a post the information submitted in this application will form the basis of my contract of employment with Leeds Mind, and that if it is subsequently discovered that I have wilfully given false information, or withheld information, I will be liable to immediate dismissal.
Leeds Mind is committed to safeguarding and promoting the welfare of Vulnerable Adults and all successful applicants will be asked to apply (through Leeds Mind) for an enhanced disclosure from the Disclosure and Barring Service (DBS) update service. However, each application will be considered on his/her merits and having a criminal record will not necessarily bar you from working for Leeds Mind. This will depend on the nature of the position and the circumstances and background of your offence(s).
Diversity Monitoring Form
Leeds Mind is striving to be a diverse employer. To ensure the effectiveness of our Diversity/Equal Opportunities practice we would ask you to complete this form and send it back with your application, but this is voluntary. All information given is treated as confidential and is used for statistical purposes only.
Please put an ‘X’ in the boxes as appropriate.
Date of birthPlease state (DD/MM/YYYY):
Gender
Male / Is your gender the same as assigned at birth?
Female / Yes
Prefer not to say / No
Other – please state: / Prefer not to say
Ethnicity
Arab / Black Caribbean / White British
Asian Bangladeshi / Black Other - please state: / White Irish
Asian Chinese / White Other – please state:
Asian Indian / Gypsy / Traveller
Asian Kashmiri / Mixed Asian & White / Other – please state:
Asian Pakistani / Mixed Black African & White
Asian Other – please state: / Mixed Black Caribbean & White / Prefer not to say
Mixed Other – please state:
Black African
Sexual Orientation / Disability
Bisexual / Do you consider yourself to have a disability?
Gay / Yes
Heterosexual / No
Lesbian / Prefer not to say
Other - please state:
Mental Health
Do you have lived experience of mental health difficulties?
Yes / Don’t know
No / Prefer not to say
Are you or have you been a carer for someone with mental health difficulties?
Yes / Don’t know
No / Prefer not to say
Signed: / Date:
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