Please return your completed application to the HR Administrator, Lifeworks Charity Limited, Blacklers, Park Road, Dartington Hall Estate, Totnes, Devon TQ9 6EQ or email to . If you have any queries regarding your application please contact us on 01803 864834

Please type or complete clearly in black Ink, continuing on separate sheets where necessary.

Position applied for: / Job Reference No:
How did you find out about this vacancy (include date):
Closing date:
1. Personal details
Surname: / Forename(s):
Preferred Name: / Contact telephone numbers:
Home:
Mobile:
Work:
Title: Mr/Mrs/Ms/Miss/Dr/Other (please specify):
Address:
Postcode: / Email address:
Our preferred method of contact is via e-mail. If this is not convenient to you please advise us of the best way in which we may contact you:
2.Further details
Do you hold a full driving licence? Yes / No
(only answer if driving is a requirement of the role) / Current licence number:
Details of any endorsements:
National insurance number: / Notice period:
Please specify any dates on which you would not be available for interview if shortlisted (e.g. holidays etc.): / If offered this position, would you continue to work in any other capacity (if so, please specify):
Please indicate if you have a disability which may require assistance from us during the recruitment process so we can provide reasonable adjustments where necessary:
3. Qualifications and training (please note that evidence of qualifications may be required)
Name and Address of Establishment/School/
College attended / Dates / Courses/Subject studied and Qualification(s) and level gained / Grade
From
month and year / To
month and year
Details of any other relevant learning and development(e.g. short courses, workplace training, computer skills etc.) Please include dates:
Professional/technical membership
Name of professional / technical body / Level of membership
4. Employment History
Current or most recent employer
Employer name and address: / Nature of business:
Job title:
Dates employed: / Current Salary:
Reason for leaving/seeking new position:
Key duties and responsibilities:
Previous employment - please list all employment history since leaving secondary education, start with the most recent (including any unpaid or voluntary work. Continue on a separate sheet if necessary)
Employer name and address and nature of business / Job title and brief outline of responsibilities / Dates
Month and Year / Starting/
leaving salary / Reason for leaving
From / To
Please give details of any gaps in your employment history:
5. Supporting statement
Please detail how your skills, knowledge, experience and achievements match the requirements for this position (you may continue on no more than 2 sides of A4):
6. References
Please give the name and contact details of two referees; these must be your current or most recent employer/s. Referees must know you in a professional capacity, not as relatives or friends. We reserve the right to take up references from any previous employer.
If you have not been employed recently or have been in full time education, a reference from your course tutor or a personal referee may be acceptable.
Please note that any offer of employment is subject to references satisfactory to us.
1st Referee name: / 2nd Referee name:
Relationship/position held: / Relationship/position held:
Company name and address: / Company name and address:
Contact number: / Contact number:
Email address: / Email address:
I agree to this reference being taken up before an offer of employment being made: Yes / No / I agree to this reference being taken up before an offer of employment being made: Yes / No
7. Additional information
Right to work
In accordance with the Asylum and Immigration Act 1996, we are required to ensure that only those legally entitled to live and work in the UK are offered employment. To comply with the act, if you are asked to attend an interview, you will be required to bring evidence of your eligibility to work in the UK:
Are you legally eligible for employment in the UK: Yes / No
Do require a work permit to work in the UK: Yes / No
Requirements under the Rehabilitation of Offenders Act 1974
As this post is covered by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 both spent and unspent convictions must be declared.
Details of any unspent convictions, cautions, pending court cases or current police investigations, or spent convictions that are not regarded as ‘protected’, should be attached to this application in a sealed envelope addressed to Human Resources. Failure to disclose this information could result in withdrawal of offer or dismissal if you are appointed.
Do you have any convictions, cautions, reprimands or final warnings either ‘unspent’ or ‘spent’ and are not ‘protected’as defined by the Rehabilitation of Offenders Act 1974: Yes / No
Lifeworks Charity Limitedaims to promote equality of opportunity and only relevant convictions will be taken into account. A criminal record will not necessarily bar you from employment withLifeworks Charity Limited.
Existing contractual terms
Are you subject to any contractual post termination restrictions or ‘restrictive covenant’ clauses? Yes / No
If yes please give further information
......
......
How much notice do you need to give your current employer? ......
Previous Employment with Lifeworks
Have you worked for Lifeworks before in any capacity, including agency work? Yes/No
If yes, please give details of the reason for leaving:
......
Data protection
I consent to my data being held and processed by Lifeworks Charity Limited and its agents in accordance with the Data Protection Act 1998:
Signature: ...... Date: ......
Applicant declaration
I confirm that the information given in this application is, to the best of my knowledge; true complete and accurate. I understand that if any information is found to be untrue, misleading or inaccurate, this may lead to withdrawal of offer or dismissal without notice.
I consent to Lifeworks using and keeping information I have provided on this application or elsewhere, as part of the recruitment process and/or personal information supplied by third parties such as referees, relating to my application or future employment. I understand that the information provided will be used to make a decision regarding my suitability for employment and if successful, the information will be used to form my personnel record and will be retained for the duration of my employment. If I am not successful, I understand that Lifeworks will retain the form for a period no longer than 12 months and that Lifeworks may use it to contact me in the event of there being any other vacancies for which I may be suitable.
Signature: ...... Date: ......

Please note that the following sections will be separated from the main application and will not form any part of the decision making process (if this form is being supplied as part of a recruitment process)

Equal Opportunities and Diversity Monitoring Form

Lifeworks Charity Limited is committed to equal opportunities for all, irrespective of sex, marital status, sexual orientation, disability, religion or belief, race, colour, nationality, age or ethnic or national origins. This form will be treated confidentially and the information provided on this form will only be used for monitoring purposes by Human Resources or if one of our regulating bodies requires it (in which case you will be asked to sign a specific consent form).

NAME:

POSITION TITLE:

GENDER: Male Female Transgender

DATE OF BIRTH:

ETHNIC ORIGIN: (please tick the box which you feel most appropriately identifies your ethnic origin)

White / Asian/ Asian British / Black/African/ Caribbean/ Black British / Duel Heritage/ British / Arab or Middle Eastern descent/ British
English, Welsh, Scottish, Northern Irish, British / / Bangladeshi / African / White & Black Caribbean / Arab /
Irish / / Indian / Caribbean / White & Black African / North African /
Gypsy or Irish Traveller / / Pakistani / Any other Black/ Caribbean/ African background / White & Asian / Kurdish /
Any other White background / / Chinese / Iraqi /
Any other Asian background

Other:

Please specify your ethnic origin, if not listed above

DISABILITY:

The Equality Act 2010 defines a disability as ‘a physical or mental impairment which has a substantial and long-term effect on the person’s ability to carry out normal day-to-day activities and which has lasted for or is likely to last for a year or is likely to recur again in the future’

Do you consider that you have a disability? Yes No

If ‘YES’ is it: Physical Impairment Mental Impairment

If ‘YES’ please give brief details of your disability in the space provided below:

RELIGION OR BELIEF:

I would describe my religious background/beliefs as:

I have no religious beliefs Prefer not to disclose

MARITAL STATUS:

Single Married DivorcedCivil PartnerSeparated

Co Habiting WidowedPrefer not to disclose

SEXUAL ORIENTATION:

Heterosexual Bisexual Gay/Lesbian Other Prefer not to disclose

DATA PROTECTION:

I agree to Lifeworks Charity Limited recording and using the personal data contained in this form formonitoring purposes:

Name: Signature:

Date:

Lifeworks Application Form January 2016