Please return this form to: Mo Smith Regenerate-RISE 22 Felsham Road Putney London SW15 1DA 020 8780 9330

APPLICATION FORM

Position applied for: Chief Executive Officer Location: Based in Putney, SW15 but travelling the UK Closing Date for Applications: 16 November 2012 Interview Date: To be arranged

Please write clearly in black ink, completing all sections of the application form and return to the address above. You are welcome to include your CV in addition to completing this form.

PERSONAL DETAILS (Please print)

SURNAME ______Mr/Mrs/Ms/Other ______

FIRST NAME (S) ______

CURRENT ADDRESS ______

______POST CODE ______

TELEPHONE NUMBER (Home) ______

WORK ______MOBILE NO ______

Email Address: ______

PREVIOUS EMPLOYMENT (please state your last three employers, dates of employment, job title and reason for leaving, starting from present employer:

Employer Dates of Job Title Reason for Leaving Employment

1 EDUCATIONAL AND SUPPORTING QUALIFICATIONS:

Dates School/College/University – starting Qualifications Achieved (please include any from Secondary School relevant to the post) (Please include any relevant Training courses applicable to the post)

1. Please explain in detail the experience you have had in relation to this post:

2 2. Please give information with regard to your Driving experience below:

Do you have a current UK Driving Licence YES/NO

Please state the year you passed your test and whether you have a D1 category on your current licence Year ______YES/NO

Do you own your own vehicle? YES/NO

Do you have any points on your licence? YES/NO

If YES, please describe below:

3. Please give information with regard to your health:

Are you in good health? YES/NO

(If NO, please give details below – if you fail to disclose a health problem, this may affect any sick pay given whilst in employment) Please state any long-standing medical problems below:

Please state how many days sick leave you have taken in the last year ______days

Do you have a disability? YES/NO If YES, please describe:

Are you registered disabled? YES/NO

4. Please give information with regard to your IT skills:

Please briefly describe your computer skills below ie Word processing, Excel, Publisher etc and your approximate typing speed:

3 5. Please outline below what you consider to be the most important priorities in caring for the elderly in today’s society (please use a separate sheet if necessary):

6. Regenerate-RISE has its values and ethos in the Christian faith

This position requires the post holder to work within several different Christian denomination Church environments as well as being able to work and liaise with people from all denominations and religious beliefs. Please outline below your personal beliefs in relation to this particular post:

4 7. Please say why you are applying for this post and why you think you are suitable for the position – please continue on another sheet of paper if necessary:

CONVICTIONS:

Have you had any criminal convictions? YES/NO

If YES, please give full details on a separate sheet

Because of the nature of the work for which you are applying, this position is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 by virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) Order 1975. Applicants are not entitled, therefore, to withhold information about convictions which for other purposes are “spent” under the provisions of the Act. In the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by REGENERATE-RISE. All information given will be completely confidential.

If you are not British, do you have a current Work Permit YES/NO

REFERENCES: Please submit three references, one of which must be your most recent employer and if appropriate one must be your Minister/Vicar/Pastor/Elder – giving the full 5 addresses, including post codes and telephone numbers (none of the referees must be related to you. If these are not given in full, or we cannot read them, your application form may be rejected) please print

(1) Employer’s Reference

NAME ______

NAME OF COMPANY/ORGANISATION ______

ADDRESS ______

______POST CODE ______

TEL NO ______MOBILE: ______

EMAIL ADDRESS ______

(2) Minister/Vicar/Pastor/Elder/Voluntary Organisation/Other

NAME ______

NAME OF CHURCH/Organisation/Other ______

ADDRESS ______

______POST CODE ______

TEL NO ______MOBILE: ______

EMAIL ADDRESS ______

(3) Other Referee

NAME ______

ADDRESS ______

______POST CODE ______

TEL NO ______MOBILE: ______

EMAIL ADDRESS ______

CAPACITY IN WHICH REFEREE IS KNOWN TO YOU ______

DECLARATIONS

I agree to Regenerate-RISE arranging a CRB check, at no expense to me. I authorise Regenerate-RISE to obtain references to support this application and accept and release Regenerate-RISE and referees from liability caused by giving and receiving information.

Please state whether we can send for references before interview: YES/NO

I declare that I am eligible to work in the UK and if appropriate, have a current work permit YES/NO

6 If you have a work permit, when is it due for renewal? ……………………………………….

I confirm that the information given on this form is correct and any misleading or falsification of information may be proper cause for rejection or termination of placement.

Signature: ______Date: ______

This is an extra box for any further comments:

Regenerate-RISE is a Registered Charity No: 1118543 Company Limited by Guarantee No: 5758108 Registered Office: The Platt Christian Centre, 22 Felsham Road, Putney, SW15 1DA 7 8