London Borough of Brent

London Borough of Brent – Application Form

Confidential

To complete the form from within a word processor, please type into the shaded fields and email to the address in the advertisement. Alternatively print and complete by hand and post to the address on the advertisement. Please Complete in type or black ink (refer to guidance notes for help)

Post Title Post Ref No Unit

Part A Personal Details

Full Name : Title Address :

Telephone No. (day) (eve) I need a work permit to work in this country Yes No If you need a work permit, please state if there are any limitations / conditions on the permit. National Insurance Number:

Please indicate if you have a disability you want the Council to take into account. Yes No

Please outline what assistance (if any) you need during the recruitment and selection process e.g. a signer

Part B Education and Training Please give brief details of courses attended and examination results, including work-based training.

Name of establishment From To Examination results (subject, level, grade)

Part C Present or most recent employment

Name and address of employer

Post held Date started Until Salary

Key roles/achievements 1. 2. 3. Reason for leaving

Employment history (Most recent First)

Key roles/achievements 1. 2. 3.

Reason for leaving Part D Experience/relevant skills/further information Use this section to show how you meet all of the short-listing criteria for the job as set out in the enclosed person specification, drawing on all aspects of your education and experience, including paid or unpaid employment, voluntary work, and home responsibilities (Please continue on a separate sheet if necessary).

Do you hold a current driving licence? Yes No If yes, please specify type of licence

Number of working days sick in the last 2 years

Number of spells of sickness in each of the last 2 years Part E Verification of employment or education record Please give names and addresses of two people who can provide employment references. One should be your present/most recent employer, Preferably your immediate manager

Name Name Address Address

Position held Position held

Tel no Tel no

If you have not been in paid employment please give the name of head of education or training establishment and/or the manager of a voluntary group for whom you have worked. Please tick this box if you do not wish the council to approach your present employer until, and if, a firm offer of employment has been made. (The Council normally takes up references if you have been short listed)

Relatives/other interests - Canvassing of Councillors or officers will disqualify you.

Are you related to a Councillor or employee of the Council Yes No If yes, please give brief details

If appointed, do you have any business and/or financial interests, which might conflict with the duties of this post? Yes No If yes, please give brief details

Rehabilitation of Offenders Act You do not generally have to disclose details of spent convictions. However, if the post you are applying for is exempt from the Rehabilitation of Offenders Act by virtue of the (Exceptions) order because it involves access to persons who are disabled, or addicted to drugs or alcohol or under 18 or over 65, you must reveal details of all convictions, spent or otherwise. (Please see guidance notes). Have you ever been convicted of any criminal offence? Yes No If yes, please give details of conviction(s) and date(s)

Please continue on a separate sheet if necessary.

Declaration I declare that to the best of my knowledge the information given on this form is correct and can be treated as part of any subsequent contract of employment. Failure to disclose information or providing deliberate false information may result in disciplinary action being taken against you.

The authority is under a duty to protect the public funds it administers and to this end may use the information you have provided on this form within this authority for prevention and detection of fraud. It may also share this information with other bodies administering public funds for this purpose.

Signature Date London Borough of Brent - Monitoring Details

Name Post Ref No

Post Applied For

Is the post applied for :- Full Time Part Time Job share

Personal Details

The Council has an Equal Opportunities Employment Policy to ensure that all applicants are treated fairly and are appointed solely on their suitability for the post irrespective of race, sex, disability, sexuality, age, non trade union & trade union membership, creed, colour, nationality, religion, language, political opinion or affiliation, gender reassignment, marital status, family connections, caring responsibilities or unrelated criminal conviction. All stages of the recruitment process are monitored to check that unfair discrimination is not taking place. Please complete the following by ticking the relevant boxes. (Please read enclosed guidance notes).

I would describe my race or ethnic origin as: White UK White Irish White Other: please specify

Mixed White and Mixed White and Mixed White: Mixed Other: Black Caribbean Black African and Asian please specify

Asian Indian Asian Asian Asian Asian Other: Pakistani Bangladeshi British please specify

Black Caribbean Black African Black British Black Other : please specify

Chinese Chinese British Chinese Other : please specify

Any other group: please specify

Please indicate your age range Sex Male Female 16-25 26-35 36-45 46-55 56-65

I have a disability I would like the Council to know about Yes No ie Mobility difficulties, Epilepsy, Diabetes, Sensory impairment, Depression etc

I have special requirements, which I’d like the Council to take into account in testing/interview Yes No

Please indicate how the Council can help you with these requirements. ie providing a signer at interview etc.

Would you like to be considered for this post as a job sharer Yes No Please state where you saw this position advertised

For Office Use - Please tick Form Entered On Database - Yes