Manual Application Form

Application form Version 09/10 Please refer to the enclosed Guidance Notes when completing your application.

Post applied for ……………………………………………Vacancy Ref …….…….…….…Applicant No. ……………….. (for internal use only)

1. Personal details Title ………………. (Miss, Mrs, Ms, Mr, Dr etc) Surname/Family Name ………………………………………

First Name(s) …………………………………………. National Insurance No. ………………………………………

Address …………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………Postcode:………………………….

Email address ………………………………………………… Can we email all correspondence? Yes No

Home telephone number …………………………………… Mobile telephone number …………………………………

Work telephone number …………………………………….. Can we contact you at work? Yes No

2. Vacancy How did you become aware of this vacancy? (Please state media/website) …………………………………………..

3. References Please give names of two referees – one of whom should be your current/ most recent line manager (paid or voluntary work). School or college leavers may list a Teacher or Tutor as one referee. If you do not have a second work referee, the second referee may be a personal referee (but not a relative). We always take up references before confirming an offer of employment.

Name ……………………………………….………………… Name ……………………………………………………….

Occupation …………………………………………………... Occupation or Relationship to you ……………………..

Company Name …………………………………………….. Company Name ……………………………………………...

Address………………………………………………………. Address ……………………………………………………….

………………………………………………………. ……………………………………………………….

…………………………Post Code ……………… …………………… Post Code …………………..

Tel. No ………………………………………………………… Tel. No ………………………………………………………..

Email ………………………………………………………….. Email …………………………………………………………. Can we take references at any time? Yes No Can we take references at any time? Yes No Is this a Personal Referee? Yes No

of 10 UK Registered Charity No: 222377 EMP03AGENERAL

of 10 4. Employment history

Current or most recent employer (including voluntary or unpaid work)

Employer Name:………………………………………………………………………………………………………………….

Address:……………………………………………………………………………………………………………………………

………………………………………………………………………………………. Postcode:…………………………

Job Title:…………………………………………………………………………… Salary :………………………….

Date started:………………… Date appointed to present/last job ……………… Notice period:……………………

Date left (if applicable) ………………………. Reason for leaving ………………………………………………………

When would you be free to take up work for us?......

Brief description of your work:

Previous employment – please give details of all jobs held/work history, including part-time and unpaid work, starting with the most recent first and explain clearly any gaps in your employment history. Employer name & address Job Title & brief outline of duties & key Date position held Reason for leaving achievements from/to (month/year)

of 10 5. Education, technical and professional qualifications What formal education, vocational/professional qualifications and training do you have? Please include everything you consider relevant. Continue on a separate sheet if necessary. Name of schools, colleges and universities Dates from/ to Certificates, diplomas, degrees or other qualifications attended obtained or expected (please include results/ grades)

6. Membership of professional bodies and status of membership

………………………………………………………………………………………………………………………………………

7. Personal development Please include any training courses, learning, voluntary work or other responsibilities you consider relevant (with dates):

………………………………………………………………………………………………………………………………………

of 10 8. What can you bring to this post? Please use this space to explain why you are interested in this post and what you can bring to it. You should relate your experience (paid or unpaid) to the job description and person specification provided in the application pack. Please continue on a separate sheet if necessary.

If you have been sent some supplementary questions you should complete these instead of this section.

………………………………………………………………………………………………………………………………………

of 10 9. Eligibility to work in the UK (Mencap undertakes rigorous checking of applicant’s eligibility to work in the UK) Are you currently eligible for work in the UK? Yes No

10. Welsh speaking applicants (for posts in Mencap Cymru only) If you are applying for a post in Wales, and the person specification for the post states that being a Welsh speaker is 'essential' or 'desirable', please state below your ability to speak Welsh: Fluently (bilingual) Can converse reasonably well, but not fluent Basic Not a Welsh speaker ______11. Disability Mencap guarantees an interview to all disabled people who meet the essential criteria for the job. It is therefore important that you tell us if you have a disability. Do you consider yourself to be disabled? Yes No ______12. Other information

Have you worked for Mencap before? Yes No If Yes, please give details

………………………………………………………………………………………………. Have you made an application to Mencap before? Yes No If Yes, please give details ,……………………………………………………………………………………………… Do you have a current full driving licence? Yes No Do you have any endorsements? Yes No Do you have the use of car for work? Yes No

Are you a close friend, partner or relation of anyone who, to your knowledge is a Yes No trustee, a national assembly member or employee of Mencap? If Yes, please state who and the relationship ……………………………………………………………………………………………….

13. Data protection statement The information that you provide on this form and that obtained from other relevant sources will be used to process your application for employment. Mencap reserves the right at any time to check on any experience, achievements, qualifications and skills claimed by you either on this application form, in any accompanying or subsequent correspondence or at interview. The personal information that you give us will also be used in a confidential manner to help us monitor our recruitment process. If you succeed in your application and take up employment with us, the information will be used in the administration of your employment. We may also use the information if there is a complaint or legal challenge relevant to this recruitment process. We may check the information collected. We may also use or pass to certain third parties information to prevent or detect crime, to protect public funds, or in other ways as permitted by law. By signing the application form we will be assuming that you agree to the processing of sensitive personal data, in accordance with our registration with the Data Protection Commissioner.

14. Declaration I declare that the information I have given in this application is accurate and true. I understand that providing misleading, false information or significant omission will disqualify me from appointment OR, if appointed, may result in my dismissal and possible referral to the police. I understand that any job offer is subject to satisfactory references and a probationary period and (if Mencap believes it appropriate) a satisfactory medical report. I understand that if this post involves working with people with a learning disability, the post may be subject to a Criminal Record Check (from the Criminal Records Bureau Disclosure Service for England and Wales; or from Access NI in Northern Ireland). Should I be offered such a post, I understand that a Criminal Record Check will be sought before the appointment is confirmed.

Signature ………………………………………………………………………….. Date ……………………………………..

of 10 Please return your completed application form as advised in the Guidance Notes, by the closing date stated.

of 10 Diversity monitoring form (confidential) Mencap recognises and actively promotes the benefit of a diverse workforce and is committed to treating all employees with dignity and respect regardless of race, age, sex, gender, disability, sexual orientation, religion, belief, marriage or civil partnership. We therefore welcome applications from all sections of the community. You can refer to Mencap’s accessible diversity policy in the Guidance Notes. Please note that this section of the form is confidential. It will be detached from your application and used solely for monitoring purposes.

Personal Gender: Male Female Date of Birth D D / M M / Y Y Y Y

Disabilities

Do you consider yourself to have a disability? Yes No

Do you consider yourself to have a learning disability*? Yes No *This means you find it harder to learn and understand things than most people. You may need support to do some things like cooking or getting dressed. You may need help with understanding numbers or talking to other people. Mencap does not include difficulties like dyslexia or dyspraxia within its definition of learning disability.

Ethnic origin - I would describe by ethnic origin as:-

White English, Northern Irish Gypsy or Irish Any other Irish British, Welsh, Traveller white * Scottish Black or Black Caribbean Black African Other Black Black British background * Mixed White & Black White & Black White & Asian Other mixed Caribbean African background * Asian or Indian Pakistani Bangladeshi Other Asian Asian British background *

Other ethnic Chinese Arab Any Other * group

* Please specify ……………………………………………………………………………………………………………….. For posts in Northern Ireland

I would describe my community background as Protestant Roman Catholic Neither community*

* Please give details …………………………………………………… For posts in Mencap Cymru

In order to help us to monitor the number of Welsh speaking staff Yes - Fluent Yes – Basic No please state whether you are able to converse in Welsh Other If you wish, you may disclose other information about yourself in this section about your

Religion

No Religion Christian (all Christian Denominations)

Buddhist Hindu Jewish Muslim Sikh Other Religion Sexual Orientation

Heterosexual Homosexual Bi-sexual

For monitoring use only - Application Reference Number : Closing Date:

of 10 Version 09/10

of 10 Diversity and equal opportunities at Mencap ______At Mencap we believe that everyone should have equal chances in life, no matter what their ability, ethnicity, gender, beliefs, circumstances or life experience may be. We want to make sure that our services and support are available to everyone, and that they are used by people from different communities. We value difference and want to recruit and retain a diverse workforce, to increase the range of skills and talents within Mencap. This makes us stronger as an organisation.

Mencap wants to support and work with people with a learning disability, their families and carers from different backgrounds.

These include:  disabled people and non-disabled people  people from black and Asian communities and white people  men and women  older people and younger people  people of different religions or beliefs  people of different sexual orientations  people who have, or are thinking about, changing their sex  people who are single or in committed relationships

We really want people with a learning disability to be involved in running Mencap. Mencap is here to make life better for people with a learning disability (as well as their families and supporters). We believe we must work with people with a learning disability to do this. We especially want people with a learning disability to work for us as staff and volunteers, and to be members of Mencap.

You can expect some things from Mencap.  You can expect not to be abused or bullied.  You can expect to be treated with respect – it should not matter how you look, whether you are a man or woman, what race you are, how old you are, your sexual orientation, if you are disabled or not, what you believe, who your friends and family are or anything else that makes you different.  If you have a complaint, you can expect that we will deal with it quickly. We will not tell anyone who does not need to know. 0 Mencap expects some things from you.  You should not be rude to, bully or treat anyone at Mencap badly. This includes staff, people who use Mencap services, Mencap members and volunteers.  You should treat everyone with respect – it should not matter what they look like, whether they are a man or woman, what race they are, how old they are, their sexual orientation, whether they are disabled or not, what they believe, who their friends and family are or anything else that makes them different.  You should tell a manager in Mencap if you think something is happening that is unfair. www.mencap.org.uk

Registered charity number 2223772010-30/09