13 Greenway Park Cocklebury Farmhouse Chippenham Cocklebury Lane, off Darcy Close SN15 1QG Chippenham 01249 443965 SN15 3QW 01249 658670 79 Malmesbury Road Chippenham [email protected] SN15 1PX 01249 651992 Outstanding Care & Support For people with learning disabilities

POST APPLIED FOR:

SURNAME FIRST NAMES TITLE

ADDRESS HOME TELEPHONE NO.

MOBILE TELEPHONE NO.

CONVICTIONS

Please give details of any conviction, including the date of conviction & the sentence imposed. N.B Road traffic offences should be included.

CONVICTION SENTENCE DATE

If your application is successful, we will be required to obtain a “Criminal Record Check” from the Disclosure & Barring Service. Employment will be conditional upon the results of this Criminal Record Check, which will indicate your suitability to work with vulnerable adults. HOW MUCH NOTICE IS HOW WOULD YOU DO YOU HOLD A REQUIRED FROM YOUR TRAVEL TO WORK? CURRENT DRIVING PRESENT EMPLOYER? LICENCE?

DATES EDUCATIONAL & PROFESSIONAL QUALIFICATIONS/DETAILS

DATES ANY OTHER RELEVANT TRAINING COURSES ie First Aid/NVQ WORK HISTORY OVER THE LAST TEN YEARS EMPLOYE POST DATES DUTIES SALARY REASON R TITLE FOR LEAVING

INTERESTS / HOBBIES

REFERENCES INCLUDING TWO MOST RECENT EMPLOYERS NAME TITLE ADDRESS & TELEPHONE PLEASE GIVE ANY OTHER INFORMATION THAT YOU THINK WOULD BE USEFUL IN CONSIDERING YOUR APPLICATION.

Please note * Deliberate omission or falsification of information could lead to the disqualification of your application or later dismissal if appointed.

TO THE BEST OF MY KNOWLEDGE THE INFORMATION GIVEN ON THIS FORM IS CORRECT.

SIGNATURE……………………………………….. DATE………………….

PLEASE RETURN TO THE ADDRESS CIRCLED ON THE FRONT OF THE FORM. DUE TO THE LARGE NUMBER OF APPLICANTS WE ARE UNABLE TO ACKNOWLEDGE ALL APPLICATIONS. IF YOU ARE NOT ASKED TO ATTEND FOR INTERVIEW WITHIN TWO WEEKS OF RETURNING YOUR APPLICATION FORM PLEASE CONSIDER THAT YOU HAVE BEEN UNSUCCESSFUL ON THIS OCCASION. THANK YOU.