Eligibility & Application Form Women S Strand

To apply for this Career Development Programme for Women, funded by the EU with ESF funds, please complete the following eligibility form, if at any time during completion you are unsure of any of the questions, please contact us on 0300 365 0445.

Eligibility & Application Form – Women’s Strand

Section 1 – Eligibility

Are you legally resident in the UK? / Yes ☐ No☐
(If no is ticked you are not eligible due to our funding criteria, please do not continue to complete this form)
Are you legally employed / self-employed in the UK? / Yes ☐ No☐
(If no is ticked you are not eligible due to our funding criteria, please do not continue to complete this form)
Gender / Female☐ Male☐
(If male is ticked you are not eligible due to our funding criteria, please do not continue to complete this form)
Is your current role funded by any other European Programmes? / Yes ☐ No ☐
(If yes is ticked you are not eligible due to our funding criteria, please do not continue to complete this form)
What sector do you currently work in? / Private ☐ Public ☐ Third/Voluntary ☐
(If public is ticked you are not eligible due to our funding criteria, please do not continue to complete this form)
Do you work or live in one of the following Local Authorities?
(Please only tick one option in each box as appropriate)
(If outside of Wales you are not eligible due to our funding criteria, please do not continue to complete this form)
Local Authority / Work / Live
Blaenau Gwent / ☐ / ☐ /
Bridgend / ☐ / ☐ /
Caerphilly / ☐ / ☐ /
Cardiff / ☐ / ☐ /
Carmarthenshire / ☐ / ☐ /
Ceredigion / ☐ / ☐ /
Conwy / ☐ / ☐ /
Denbighshire / ☐ / ☐ /
Flintshire / ☐ / ☐ /
Gwynedd / ☐ / ☐ /
Isle of Anglesey / ☐ / ☐ /
Merthyr Tydfil / ☐ / ☐ /
Monmouthshire / ☐ / ☐ /
Neath Port Talbot / ☐ / ☐ /
Newport / ☐ / ☐ /
Pembrokeshire / ☐ / ☐ /
Powys / ☐ / ☐ /
Rhondda Cynon Taff / ☐ / ☐ /
Swansea / ☐ / ☐ /
Torfaen / ☐ / ☐ /
Vale of Glamorgan / ☐ / ☐ /
Wrexham / ☐ / ☐ /
Outside Wales / ☐ / ☐ /
Is the Company that you are employed by (not your actual job in the Company) categorised in one of the following priority industry sectors?
Yes ☐ No ☐(please see question below)
(If you have any queries about whether your Company fits into one of the relevant priority industry sectors below please contact us on 0300 365 0445)
Priority Industry Sector
Advanced Materials & Manufacturing
Energy & Environment
Food & Farming
ICT
Creative Industries
Life Sciences
Tourism
Construction
Finance & Professional Services
Do you have an interest in working in one of the following priority industry sectors and have identified an opportunity that will allow you to achieve this?
If you have already ticked the section above stating that you are currently employed in one of the priority sectors, you do not need to complete this section as well
Yes ☐(please tick which sector and complete comments box below)
No ☐(If no is ticked you are not eligible due to our funding criteria, please do not continue to complete this form)
Priority Industry Sectoryou have identified an opportunity: / Please tick
Advanced Materials & Manufacturing / ☐ /
Energy & Environment / ☐ /
Food & Farming / ☐ /
ICT / ☐ /
Creative Industries / ☐ /
Life Sciences / ☐ /
Tourism / ☐ /
Construction / ☐ /
Finance & Professional Services / ☐ /
If you have stated that you are not employed in any of the priority industry sectors listed above but do have an interest, please tell us more about the opportunity you have identified including the job title and a brief description of the role identifying specific skill requirements.
Please tell us why you would like to take part in this career development programme for women
Please tell us what you are hoping to gain from taking part in this career development programme
How did you hear about ChwaraeTeg / Agile Nation 2 Programme?
☐Facebook☐Word of Mouth☐Newspaper
☐Twitter☐Flyer☐Other
☐Linked in☐CT Website☐ChwaraeTeg staff member
Name:______
☐Promotional Event☐ Radio

Thank you for successfully completing our eligibility criteria, at this stage you appear to be eligible for our career development programme and can move on to the application section of the form. In order to complete the information on this form, you will require your latest payslip and employment & qualification details. At any time during completion you are unsure of any questions, please contact us on 0300 365 0445.

Section 2 –Personal Details

Contact Title: / Miss ☐ Mrs ☐ Ms ☐ Dr ☐ Other ☐
Forename: / Middle Name:
Surname / Family Name:
House No. / Name: / Postcode:
Street Name:
Town: / Local Authority:
Date Of Birth: / NI Number:
Telephone Number: / Work/Home (please delete as applicable) / Daytime ☐ / Evening ☐ / Anytime ☐
Mobile Number: / Work / Home (please delete as applicable) / Daytime ☐ / Evening ☐ / Anytime ☐
Email Address:
(please provide the email address you check most frequently) / Work/Home (please delete as applicable)
Preferred Language for Communication / interaction: / English ☐ Welsh ☐
Please give an indication of which Local Authority areas (listed on first page) are most convenient for you to attend: / First Choice ______
Second Choice ______
Are there any special adjustments you require ahead of attending your first meeting? / Yes ☐ No ☐
Details______

Section 3 – Employment and Qualification Details

Are you: / Employed ☐ Self Employed ☐
Current Job Title:
Please select what employment contract you have: / Permanent ☐ Zero Hours ☐
Temporary ☐ Agency ☐
Fixed Term ☐
Are you currently on Maternity Leave or on a Secondment? / Maternity
Yes ☐ No ☐ / Secondment
Yes ☐ No ☐
Company’s Registered Name: (as it appears on your payslip)
Trading name of Company (if applicable)
Company’s Address at which you are based:(please provide the address at which you are contracted to work)
Street Name/No: / Postcode:
Town: / Local Authority:
Telephone Number:
Head Office address (if different to above)
What is the main activity of the Company?
Do you give your consent for us to contact your employer: / YES☐ / NO☐
What is the highest level of qualification you currently hold?
(This information is not used to assess your suitability to complete the career development training, it is required as a base line for our interventionbyr our funders) / None / ☐ /
Below CQFW Level 2 / ☐ / e.g. GCSEs grades D-G, NVQ Level 1
CQFW Level 2 / ☐ / e.g. GCSEs grades A-C, NVQ Level 2
CQFW Level 3 / ☐ / e.g. ‘A’ Levels, NVQ Level 3, BTEC Nationals
CQFW Level 4 - 6 / ☐ / e.g. HNCs and HNDs, NVQ Levels 4-6, Graduate Certificates and Diplomas
CQFW Level 7 - 8 / ☐ / e.g. Masters, Postgraduate Certificates and Diplomas, Doctorates
Have you ever received any Team Leading or Management training? / Yes☐No☐
If yes please state what training and at what level:
If the training was accredited please state training provider:
When was this training provided?

Section 4 – Equality Information - This information will not be used to assess your ability to complete the career development programme;ChwaraeTeg works to provide development opportunities for Women particularly those facing multiple barriers to progression

Are you a single adult household?
(A single adult household is where the household includes only one adult aged 18 or above irrespective of their employment status) / Yes☐No☐
Do you have one or more dependent child/children?
(Individuals aged 0-17 or 18-24 in full time education) / Yes☐No☐
If yes, are they? / 0 – 17☐18 – 24☐Both☐
Do you have caring responsibilities?
(A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support) / Yes ☐ (please select from options below) No ☐

Primary carer of a disabled child / children (under 18) ☐

(Is this your dependent child?) Yes ☐ No ☐

Primary carer of a disabled adult (18 and over) ☐

Primary carer of older person / people (18 – 64) ☐

Primary carer of older person / people (65 and over) ☐

Do you:
Understand Welsh
Speak Welsh
Read Welsh
Write Welsh / Yes ☐No ☐
Yes ☐No ☐
Yes ☐No ☐
Yes ☐No ☐
Your Age Category:
16 - 19☐ 20 - 24 ☐ 25 – 34☐ 35 - 44 ☐ 45 - 54 ☐ 55 – 64 ☐ 66 – 74 ☐ 75+ ☐
Please state what you consider to be your Nationality:(Is considered as belonging to a particular nation whether by birth or naturalisation)
Ethnicity
White: / Mixed / Multiple ethnic groups:
English/Welsh/Scottish/Northern Irish/British ☐
Irish ☐
Gypsy/Traveller/Irish Traveller ☐
Other White background ☐ / White and Black Caribbean ☐
White and Black African ☐
White and Asian ☐
Any other mixed / multiple ethnic ☐
Asian / Asian British: / Black / African / Caribbean / Black British:
Indian ☐
Pakistani ☐
Bangladeshi ☐
Chinese ☐
Any other Asian background ☐ / African ☐
Caribbean ☐
Any other Black/African/Caribbean background ☐
Other ethnic group: / I do not wish to disclose my ethnicity ☐
Arab ☐
Any other ethnic group ☐
If you have selected your ethnicity as other, please tell us what it is:
Do you consider yourself to be a Gypsy/Traveller/Roma? / Yes☐No☐
Are you a Migrant Worker?
If YES, are you:
(A migrant is classed as a person who has changed their country of residence for a period of at least a year to the UK, but is not a citizen of the UK) / Yes☐No☐
EU☐non – EU☐
Do not wish to disclose this information☐
Previous Country of residence:
Date application completed:

Thank you for completing the application form a member of our team will now asses the information you have provided and contact you shortly to discuss your individual requirements.

AN2 WP 01 Eligibility & Application Form
Version: 3 / Version date: January 2016 / Approved by:
QPI Lead / Initialled:
HB / Issue date:
14th January 2016 / Page 1 of 10
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