Non Teaching Staff Application Form

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Job Title* Job Reference Title* Applicants Name* Date of Birth* Mobile Number* Landline* Email Address* National Insurance Number* Address*

Two Ticks

Under the 'Two Ticks' Scheme the Governing Body undertakes to interview disabled people who meet minimum essential criteria detailed on the person specification.
For these purposes, disability is defined as any physical or mental impairment which has a substantial and long term (over 12 months) adverse effect on your ability to carry out normal day-to-day activities.

Do you consider that you would qualify for an interview under the SchemeYesNo

If you need any particular arrangements to be made for interview e.g access, sign interpreter, induction loop system, taping of documents etc, please specify them below.

Specify here:

Canvassing and Relationships

If you are related to or have a close personal relationship with a member of staff or an elected Member or and employee of the Council, please state their name and relationship to you.

Name Relationship

Canvassing may lead to disqualification for appointment

Education, Training and Qualifications

Name of School/ College or University attended From To

Qualifications including Grades

Schools Name and Address (After the age of 11)*

	Name of School(s)	Qualification	Grade	Date obtained

Further or Higher Education (Full and Part-time)

	Name and Address	Qualification	Grade	Date obtained

Professional or other courses including training attended, NVQs etc

	Name and Address	Qualification	Grade	Date obtained

Current membership of professional organisations

	Name or Organisation	Membership details

Do you hold a current, valid driving licence? Please describe Car/ LGV/ PCV*

Do you own a car*YesNo

Do you have access to one?*YesNo

Employment (Please include any previous experience either paid, unpaid or voluntary starting with the most recent)

Current employment name and address Current Employment Details*

	Position Held and brief description of duties	Current Salary	Date Finished (If appropriate)	Period of Notice
1.

Previous*

	Employer/Organisation	Position held and brief description of duties	Dates from / to	Reason for leaving
2.

Additional Information

Please explain how your skills, abilities, experience and achievements to date would make you a suitable candidate for this post (including leisure and voluntary). Please refer to the criteria on the person specification.

Convictions/ Disqualifications

As the work of this post involves working with children, other vulnerable groups or in a position of trust it is therefore exempt form the provisions of the Rehabilitation of Offenders Act 1974. The County Council will check with the Disclosure and Barring Service (DBS) to see if you have any criminal convictions.
If this post meets 'Regulated Activity' (as defined in the Safeguarding Vulnerable Groups Act 2006 as amended by the Protection of Freedoms Act 2012) the relevant barred list(s) for children and adults will also be checked.
You must disclose details of all unspent and unfiltered spent reprimands, formal warnings, cautions and convictions as these will be supplied by the DBS. Please see: www.gov.uk/government/publications/filtered-rules-for-criminal-record-check-certificates for information regarding filtering of convictions.
Any information given will be treated as confidential. You should note that disclosing a conviction does not necessarily bar you from appointment. Failure to disclose may result i t he withdrawal of your application or dismissal from any job offer in relation to this form.
Please give details and dates of any unspent and unfiltered spent criminal convictions, disqualifications, cautions or driving offences (or alternatively state 'none' if that is the case)

References

Please give details of two people, one of which should normally be your current line manager, who are able and willing to comment on your suitability for this job.

Reference 1. Name & Address* email address* Telephone number* Relationship to your e.g. Manager, colleague etc:*

Do you wish to be consulted before this referee is approached*YesNo

Reference 2. Name and address* Email address* Telephone number* Relationship to you e.g Manager, colleague etc:*

Do you wish to be consulted before this referee is approached*YesNo

Declaration*

Declaration*I agreeI don't agree

Select Date* Please attach a supporting statement and information that might be relevant or assist in your application here.