THE SIMON COMMUNITY – APPLICATION FOR EMPLOYMENT

POSITION APPLIED FOR ______
Family name / First name(s)
Address:
Postcode:
Telephone Number: Email Address:
Do you require a work permit to work in the UK? Yes ¨ No ¨
(If yes, please provide details):

EDUCATION HISTORY

Schools/Colleges/Universities: Qualifications gained:
Relevant training completed:
EMPLOYMENT HISTORY
Most recent first, include paid/unpaid employment (add separate sheet if required)
Date start / end:
Position:
Employer:
Town / City
Duties & Responsibilities
Reason for leaving:
Date start / end:
Position:
Employer:
Town / City
Duties & Responsibilities
Reason for leaving:
Date start / end:
Position:
Employer:
Town / City
Duties & Responsibilities
Reason for leaving:
Date start / end:
Position:
Employer:
Town / City
Duties & Responsibilities
Reason for leaving:
Please give details here of your reasons for applying for this post and how you meet the requirements of the post, detailed in the person specification (attach additional sheet if necessary):

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REFERENCES

Please note here the names and addresses of two referees, one of whom must be your most recent employer, from whom we may obtain both character and work experience references.
Name:
Relationship to you:
Address:
Telephone number:
Email address: / Name:
Relationship to you:
Address:
Telephone number:
Email address:

HEALTH DETAILS

Do you consider yourself to have a disability according to the terms of the Equality Act 2010 Disability Legislation? Yes ¨ No ¨
If you would like us to make any reasonable adjustments to support you during the recruitment process or to assist you in carrying out the duties of the post, please provide details of your disability and any adjustments you think you may need.

DISCLOSURES

Do you have any convictions, cautions, reprimands or final warnings that are not ‘protected’ as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013) Yes ¨ No ¨
Please provide details of dates, conviction and any context or circumstances leading to this offence:

DECLARATION

I confirm that the above information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.

Signed: ………………………………………………….. Date: ………………………………………..

Please return this form to: or post it to:

R Cullen, The Simon Community, St Josephs House, 129 Malden Road, London NW5 4HS

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THE SIMON COMMUNITY - EQUAL OPPORTUNITIES MONITORING FORM

The Simon Community is committed to eliminating discrimination from employment practices. This means that no job applicant or employee receives less favourable treatment on the grounds of age, gender, ethnicity, religion or belief, marital or parental status, social class, nationality, sexual orientation or disability. To assist us in monitoring the effectiveness of our policy you are requested to complete this form, which will be detached from your application prior to short-listing. Please sign below to indicate your agreement that we may process the information you provide and use it for monitoring purposes only, in accordance with the data protection act 1998.

Name: ………………………… Signed: …………………………. Date:……………………….

Post Applied For: ………………………………………………………………………………….

Gender: Please tick: Male □ Female □ Prefer not to say □

Disability:

Do you consider yourself to have a disability or long term health condition?

Yes □ No □ Prefer not to say □

If yes, what is the effect or impact of your disability or health condition?

………………………………………………………………………………………………………

Prefer not to say □

Ethnic Origin:

Please tick the box below which best describes your ethnic origin. Ethnic origin categories are not about nationality, place of birth or citizenship but are about the group to which you feel as an individual you belong. Please tick one or more of the appropriate boxes below:

White / □ British
□ Irish / □ Any other white background (please write below)
______
Mixed / □ White and Black Caribbean
□ White and Black African
□ White and Asian / □ Any other mixed background (please write below)
______
Asian or Asian British / □ Indian
□ Pakistani
□ Bangladeshi / □ Any other Asian background (please write below)
______
Black or Black British / □ Caribbean
□ African / □ Any other Black background (please write below)
______
Chinese or other ethnic group / □ Chinese / □ Any other ethnic background (please write below)
______

Religion: Please tick the box below that best describes you:

Buddhist / □ / Christian / □ / Hindu / □ / Jew / □ / Muslim / □ / Sikh / □
Other religion or belief / □ / No religion / □ / Prefer not to say / □

If you have ticked ‘Other religion or belief’ please state………………………………......

Sexual Orientation: Please tick the box below which best describes your sexual orientation:

Heterosexual / Straight / □ / Gay man / □ / Gay woman / Lesbian / □ / Bi-Sexual / □ / Transgender/Transsexual / □
Other / □ / Prefer not to say / □

Thank you for completing this form

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