RESTRICTED WHEN COMPLETE

WARWICKSHIRE AND WEST MERCIA COMMUNITY REHABILITATION COMPANY

PLEASE DO NOT WRITE/TYPE IN THIS BOX – FOR OFFICE USE ONLY

/

Candidate

Ref / CPSup
Nun
Feb16

PERSONAL DETAILS FORM

Please complete this application form in full and return to: Human Resources Department, Warwickshire and West Mercia Community Rehabilitation Company, Head Office, Stourbank House, 90 Mill Street, Kidderminster, Worcs DY11 6XA or email to
Appendices other than continuation sheets will not be considered.

FOR COMPLETION BY CANDIDATE

PLEASE INDICATE HERE THE POSITION YOU ARE APPLYING FOR

Job Title / Part time (16 hpw) CP Supervisor, Nuneaton / Closing date / Friday 18th March 2016
(12 noon)
Where did you see this post advertised?
PERSONAL DETAILS (BLOCK CAPITALS PLEASE)
Forename(s) / Surname
Address / Preferred Title
e.g. Mr/Mrs/Miss/Ms
Home
Telephone No.
Post Code / Mobile
Telephone No.
Email

REFERENCES

Request for references will only be processed following an offer of appointment. The first reference should be your current or last employer, or course tutor. You must provide referee details that cover a minimum period of 5 years. Please use a continuation sheet if required.
Name / Address
(please ensure that you provide the full address) / Occupation
/Position
Tel No: / Email:
Tel No: / Email:
/ Candidate
Ref / CPSup
Nun
Feb16

PRESENT EMPLOYMENT DETAILS

Name and Address of Present Employer / Department/Section
Post Held
Date Appointed
Current Salary / £ / Other Allowances
Notice required by your employer
PREVIOUS EMPLOYMENT
(Please list in order, most recent first and include any periods of voluntary work.
Please give reason for any gaps in employment record)
From / To / Name and Address of Employer / Post Held / Reason for Leaving
RELEVANT QUALIFICATIONS AND/OR TRAINING
(Please list in order, earliest first)
Completion Date / Description of Training/Course / Awarding Body
CRIMINAL CONVICTIONS
Rehabilitation of Offenders Act 1974 – The National Probation Service is exempt from the provisions of Section 4 of the above Act. This means that you must disclose ALL previous convictions, as an adult or juvenile, whether spent or not. You must also declare all cautions, bind overs, any road traffic offence, awards made by Courts Martial, or any pending proceedings. Failure to fulfil this requirement could result in any offer of employment being withdrawn. Please note that the existence of previous conviction(s), caution(s) or bind over(s) will not automatically disbar any candidate. Each case will be carefully considered on its individual merits.

Have you ever been convicted of a criminal offence, or been the subject of a bind over or caution? /
Yes No
Do you have any charges pending? /
Yes No
If the answer is YES to either of these questions, please give details, including the nature of offence(s) and date(s) of conviction(s), bind over(s) or caution(s).
Current Full Driving
Licence / Yes No

SUITABILITY FOR THIS POSITION

Please state how your skills and experience match the requirements of the job by referring to the job description and person specification.

(max 750 words)
Word
Count


Head Office, Stourbank House, 90 Mill Street, Kidderminster, DY11 6XA
Tel 01562 748375 Fax 01562 748407 Email
www.wwmcrc.co.uk
Serving Herefordshire Shropshire Telford & Wrekin Worcestershire
Diversity Monitoring Form
This Service aims to be an equality of opportunities employer and staff are selected solely on merit irrespective of race, sex, sexual orientation, disability, age, or any condition or requirements which cannot be shown to be justified. All information which you disclose will be held under the principles of the Data Protection Act. This sheet will be detached from your application prior to short listing. Information will be treated as confidential information and may be held for up to one year for the purposes of monitoring equality of opportunity in our recruitment and selection procedure.
Personal Details:
Gender: / Male / Female
Date of Birth:
Sexual Orientation – Please tick against one of the following:
Bisexual / Heterosexual
Gay Woman / Lesbian / Asexual
Gay Man / Prefer not to say
Ethnic Origin – Please tick against one of the following:
White / Black or Black British
British / African
Irish / Caribbean
Other / Other
Please specify………………………………... / Please specify………………………………...
Mixed / Chinese or other Ethnic Group
White and Black Caribbean / Chinese
White and Black African / Other
White and Asian / Please specify………………………………...
Other
Please specify………………………………...
Asian or British Asian / Prefer not to say
Indian
Pakistani
Bangladeshi
Any other Asian background
Please specify………………………………...
Religion or Belief – Please tick against one of the following:
No Religion / Atheist / Muslim
Buddhist / Sikh
Christian / Other
Hindu / Please specify………………………………...
Jewish / Prefer not to say
Disability
The Equality Act (2010) defines a disabled person as someone who has a physical or mental impairment
which has a substantial and adverse long-term effect on his or her ability to carry out normal day to day activities. Conditions covered may include (but are not limited to) severe depression, dyslexia, diabetes, epilepsy and arthritis etc.
Do you consider yourself to be disabled within the meaning of the Equality Act (2010)?
Please tick one of the following:
Yes / No / Prefer not to say
Please tick any of the following that apply to you. You may identify with more than one:
Hearing impairment
Reduced physical capacity including difficulty with physical coordination
Speech impairment
Severe disfigurement
Visual impairment (not corrected by glasses or contact lenses)
Mental illness
Reduced mobility
Learning difficulties
Progressive condition (e.g.cancer, muscular dystrophy, HIV, multiple sclerosis)
Dyslexia
Other Please specify………………………………......
Note: We guarantee to interview applicants with a disability (within the definition of the Act), who are deemed to meet the minimum criteria for the job.
Declaration:
I confirm that the information given in this application is complete and correct to the best of my knowledge. I understand that any appointment is subject to medical clearance and satisfactory references.
Signature: / Date:

Please complete this application form in full and return to: Human Resources Department, Warwickshire and West Mercia Community Rehabilitation Company, Head Office, Stourbank House, 90 Mill Street, Kidderminster, Worcs DY11 6XA or email to

Appendices other than continuation sheets will not be considered.

1

August 2014