EmploymentApplication Form

Confidential

Please note: refer to the completion notes and fill in all relevant sections of the application form either in black ink or type. Please also attach a full copy of your CV

Post details
Position applied for: Chief Executive
Section A - Personal details
Surname:
/ First Name:
Email address:
Address:
Postcode: / Home No:
Mobile: / Work No:
Do you hold a current driving licence? / Yes No
Do you have use of a car (if relevant to the post)? / Yes No
Are you a close relative of any current or former employee or Board Member of Cornwall Mobility Centre? / Yes No
If yes, please give details:
One reference must be your current or last employer. A reference from a relative is not acceptable.
Please indicate if references can be requested before interview
Reference 1 Yes No Reference2 Yes No
References (We normally only take up two references on the candidate selected for appointment)
Name: / Name:
Organisation: / Organisation:
Address incl.
postcode: / Address incl. postcode:
Relationship: / Relationship:
Tel: / Tel:
Email: / Email:

Section C – Education and Training

Secondary education
Dates attended / Level (i.e. GCSE, O, A) / Summary of qualifications obtained
Further/Higher education(include NVQ/SVQ, Degree, Diploma etc.)
Dates attended / Place of Learning / Qualifications Obtained
(Subject, Level and Grade)
Registration Status (if applicable)
Registered Body, e.g.EngC, NMC, HCPC / Registration number
Professional qualification(s)
Date / Name of Professional Body / Membership Grade (current)
Training(please give details of any other relevant training you have received)
Date / Course attended / Qualifications

Section D – Employment record

Current employment(if you are not in employment, leave this part blank)
Job Title:
Employer’s Name and Address:
Date started: / Nature of business:
Salary and benefits: / Notice required:
Summary of your duties and responsibilities and why you are looking to change roles:
Previous employment
Please provide brief details here and full employment history on your CV
Name and address of employer / From - To / Job title, duties, responsibilities and reason for leaving
Section E – Additional information
Complete the questions below using a separate additional sheet if required. Refer to the Information Pack for guidance on this section. Please keep your answers concise and focussed and use no more than 2 sides of standard A4 text.
  1. Explain how you have previously delivered business/organisational improvements, evidencing results and the achievement of key performance goals.
  2. Describe how you have led in the implementation of a business development strategy, underpinned by financial modeling, and resulting in a sound business plan and improved financial performance
  3. Evidence your skills and experience in relation to developing capacity in people, and empowering others to excel
  4. Describe how you have led an organization, or part of one, in a change situation to develop new services or products, or taken existing services/products to new markets
  5. Explain what effective governance involves and describe how you have worked, or would propose to work, with a Board and senior staff to maintain and develop a successful governance structure and strong team-working ethic.
  6. Give an example of how you have used networking to benefit either your organization or an initiative you have led.

Section F - Declaration
Have you been employed by Cornwall Mobility Centre within the last 12 months? If so, please give details:
I declare that all details and information given in this application for employment are true to the best of my knowledge. I accept that knowingly to have given false information will invalidate the application and, if considered pertinent by Cornwall Mobility Centre, could lead to the withdrawal of any offer of employment prior to work commencement or could result in dismissal or disciplinary action if employment has commenced.
I accept that Cornwall Mobility Centre will use the information contained in these application forms, to consider my application and that it will be retained in a personnel file if I am successful. I accept that the sensitive personal data contained in the Equal Opportunities Monitoring Form will be used for monitoring purposes.
Signature: / Date:

The Cornwall Mobility Centre is committed to equality of opportunity in employment. We welcome your application irrespective of gender, disability, race, colour, ethnic or national origin, nationality, sexual orientation, gender reassignment, marital status, age, religion or belief

ADDITIONAL INFORMATION
How many days have you been absent in the last three years? (most recent first) / Yr 1
Yr 2
Yr 3
If you hold a current driving license – do you have any current endorsements or motoring offences
Yes / No
If you have a disability are there any arrangements that we can make for you if you are called for an interview?
Yes / No
If Yes, please specify:
REHABILITATION OF OFFENDERS
Staff employed by the Cornwall Mobility Centre are required to declare any convictions including those considered spent. Failure to declare the following matters will result in action under the Centre’s disciplinary procedure,up to and including dismissal.
Have you ever been convicted of any criminal offence, been issued with a police caution or are subject to any pending criminal proceedings?
Yes / No
Have you ever been subject to an investigation by your employer or any other party in respect of fraud, theft, assault or any matter of conduct?
Yes / No
If you have answered yes to either of the above, specify details below:

Criminal record and barring check requirements

All applicants should be aware that this post is subject to the requirement for a Disclosure and Barring (DBS) Check(which replaced the term CRB check from 10/09/2012) under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended) and the Police Act 1997 (Criminal Record) Regulations 2002 (as amended).

CONFIDENTIAL- APPLICATION FOR EMPLOYMENT

EQUAL OPPORTUNITIES RECRUITMENT MONITORING FORM

The Cornwall Mobility is committed to ensuring that all job applicants and members of our staff are treated equally and not discriminated against on the grounds of age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage and civil partnership, and pregnancy and maternity. This form helps us to adhere to equal opportunities best practice and make progress towards identifying any barriers to diversity among our workforce. Please complete this form and return it with your application. The form will be separated from your application on receipt and will play no part in the recruitment process. Should your application be successful, the form will not be placed on your personnel file.You are not obliged to answer all the questions but the more information you supply, the more effective our monitoring will be. All information supplied will be treated in the strictest confidence. Thank you for your assistance.

PLEASE ENTER A CROSS IN THE APPROPRIATE BOXES

Post applied for: / Chief Executive
Gender / Female / Male
Prefer not to say

Age

16-20 / 21-30 / 31-40 / 41-50 / 51-60 / 61-65 / 65+

Ethnic Origin

How would you describe yourself?

Choose ONE section from A to E, and then tick the appropriate box

A Asian or Asian British

Bangladeshi

Indian

Pakistani

Any other Asian background, please write in box ......

B Black or Black British

African

Caribbean

Any other Black background, please write in box ......

C Chinese or other ethnic group

Chinese

Any other, please write in box ......

D Mixed Heritage

White and Asian

White and Black African

White and Black Caribbean

Any other Mixed background, please write in box ......

E White

British

English

Irish

Scottish

Welsh

Any other White background, please write in box ......

F Prefer not to say

Disabilitymonitoring

To make positive changes, (Company name) wants to address the different barriers faced by disabled people. Many people who do not consider themselves to be disabled may be covered by the Equality Act 2010 because they have a health condition that has an impact on their lives.
What do we mean when we say disability?
  • Do you have a physical or mental impairment?
  • Is it long term?
  • Does this make it difficult for you to do the things that most people do on a fairly regular and frequent basis?
If so, you may have rights under the Equality Act 2010. This includes people who are receiving treatment or using equipment (except glasses or contact lenses) that alleviates the effects of an impairment or a condition, people with an impairment or condition that is likely to recur, people who have conditions that will get worse over time and people with severe disfigurements.
Employees with a disability or health condition are entitled in law to ‘reasonable adjustments’ to address their needs for support in the workplace. Therefore we are interested in any disability or health condition that may require a reasonable adjustment to overcome any such barriers.

Monitoring questions:

Do you consider yourself to have a disability or a long-term health condition?
Yes No
What is the effect or impact of your disability or health condition?
Prefer not to say
If you would like to discuss your response, or are unsure of the types of reasonable adjustment that might be possible, please contact your manager who is trained to help and support you.

Disability monitoring

To make positive changes, (Company name) wants to address the different barriers faced by disabled people. Many people who do not consider themselves to be disabled may be covered by the Equality Act 2010 because they have a health condition that has an impact on their lives.
What do we mean when we say disability?
  • Do you have a physical or mental impairment?
  • Is it long term?
  • Does this make it difficult for you to do the things that most people do on a fairly regular and frequent basis?
If so, you may have rights under the Equality Act 2010. This includes people who are receiving treatment or using equipment (except glasses or contact lenses) that alleviates the effects of an impairment or a condition, people with an impairment or condition that is likely to recur, people who have conditions that will get worse over time and people with severe disfigurements.
Employees with a disability or health condition are entitled in law to ‘reasonable adjustments’ to address their needs for support in the workplace. Therefore we are interested in any disability or health condition that may require a reasonable adjustment to overcome any such barriers.

Monitoring questions:

Do you consider yourself to have a disability or a long-term health condition?
Yes No
What is the effect or impact of your disability or health condition?
Prefer not to say
Disability

Disability monitoring

To make positive changes Cornwall Mobility Centre wants to address the different barriers faced by disabled people. Many people who do not consider themselves to be disabled may be covered by the Equality Act 2010 because they have a health condition that has an impact on their lives.

What do we mean when we say disability?

  • Do you have a physical or mental impairment?
  • Is it long term?
  • Does this make it difficult for you to do the things that most people do on a fairly regular and frequent basis?

If so, you may have rights under the Equality Act 2010. This includes people who are receiving treatment or using equipment (except glasses or contact lenses) that alleviates the effects of an impairment or a condition, people with an impairment or condition that is likely to recur, people who have conditions that will get worse over time and people with severe disfigurements.

Employees with a disability or health condition are entitled in law to ‘reasonable adjustments’ to address their needs for support in the workplace. Therefore we are interested in any disability or health condition that may require a reasonable adjustment to overcome any such barriers.

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

Yes No

What is the effect or impact of your disability or health condition?

Prefer not to say

Sexual orientation

What is your sexual orientation?

Bisexual

Gay man

Gay Woman / Lesbian

Heterosexual / Straight

Other

Prefer not to say

Religion and belief

Please tick the box that best describes you:

Buddhist

Christian

Hindu

Jew

Muslim

Sikh

Other Religion or Belief (please state) ......

No Religion

Prefer not to say