Application Form
Position applied for Full Name Previous names Address Date of Birth Phone/Mobile Email NI number 1 Language nd/2 Language spoken st Qualifications/ Institution Qualification Achieved Current / Studies Awarding Body Provide details of your education from secondary stage onwards. If necessary please continue on a separate sheet. Date Awarded Date Date Reason for Leaving employment employment started ended Employment History Previous work record (starting with the most recent) in chronological order since leaving school. Include periods of voluntary work and reasons for any gap of employment. Please continue on a separate sheet if necessary Name and Job Address Title of Employer Personal Statement Please use this section to explain why you are interested in this particular position at Chrysalis and how you feel that you meet the requirement of the Person Specification. Names and contact details of three References Name Job title Contact details Relationship to you Please be aware that we are required to obtain references prior to interview for all shortlisted applicants. If you are shortlisted for interview we will contact you to obtain your consent prior to approaching your referees. General Information Do you have a disability for which you would need adjustments to the workplace or for the interview process? (if yes please supply details on a separate sheet.) Do you have a medical condition that we should be aware of as a potential employer? (if yes please supply details on a separate sheet.) What is your nationality? Do you require a visa to work legally in the U.K? How many days of sick leave you have taken in the last 12 months? YES / NO YES / NO YES / NO Have you ever been dismissed or given a disciplinary warning YES / NO from any previous employer? (if yes please supply details on a separate sheet.) Do you have a full, clean driving licence? Do you have any family or close relationships to anyone associated with Chrysalis? (e.g. existing employees or trustees). if yes please supply details on a separate sheet.) Disclosure of a criminal record YES / NO YES / NO Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4 (2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act (Exemptions) Order 1975. Applicants are, therefore, required to give all relevant information about all convictions, cautions and bind-overs, including those which for other purposes are “spent” under the provisions of the Act, and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the Order applies. Do you have any prosecutions pending? Do you have any criminal convictions, cautions or bind-overs (whether spent or not under the Rehabilitation of Offenders Act)? Yes / No Yes / No If you have answered „yes‟ to the above two questions then please provide details to the Principal in a sealed envelope marked “Strictly Confidential” and return the envelope with your application. Any offer of employment will be subject to a number of checks and clearances including a satisfactory Enhanced CRB Disclosure being obtained (see www.crb.org.uk) for more details. Declaration The information on this form will be processed in accordance with the Data Protection Act 1998 and by signing this form you are consenting to this information being processed. If you are subsequently employed by Chrysalis, this information will form the basis of your employment records, otherwise it will be destroyed approximately 6 months after the vacancy is filled. By signing also, you confirm: that to the best of your knowledge the information you have provided is correct and gives a fair representation of your qualifications, skills and employment history. You should understand that these details will be held as part of your official employment record and if any misleading information has been given, this may lead to the termination of your employment. that you are not on List 99, disqualified from working with children, or subject to sanctions imposed by a regulatory body. that you either have no criminal convictions, cautions, bind-over or prosecutions pending, or you have attached details of your record in a sealed envelope marked confidential. Signature ....................................……….... Date .......................................................
