PRIVATE and CONFIDENTIAL Please Complete This Form in BLOCK CAPITALS

Application Form www.derwentliving.com PRIVATE AND CONFIDENTIALPlease complete this form in BLOCK CAPITALS Position applied for: Personal details Title: First Name: Surname: Do you hold a current valid driving licence? YES NO Do you have use of a vehicle? YES NO Contact Details Address: Postcode: Daytime contact no: Evening contact no: Work contact no: Email address:

Your education Secondary/Comprehensive/Grammar School Establishment, qualification and subject: Grades:

Further Education Establishment, qualification and subject: Grades:

Higher Education Establishment, qualification and subject: Grades:

Specialist/relevant training –

Please detail establishment attended, subject studied and grades obtained Are you a member of a professional organisation? YES NO If yes, please give details:

Career path Current/Most recent position Company: Dates from: to: name: Position: What do you enjoy about your current job?

Outline your current responsibilities:

Key achievements:

Reason you want to move on:

Current salary package: Previous position 1 Company: Dates from: to: name: Position: Salary on leaving:

Reasons for leaving: Key achievements:

Previous position 2 Company: Dates from: to: name: Position: Salary on leaving:

How do you meet the requirements of the role? Referring to the role profile and person specification for this position, please outline why you are the right person for this job. Please set out clearly, using examples, as to how you meet the person specification.

The Derwent Living way Derwent Living are looking for colleagues who ensure not just ‘what they do’ but the ‘way they do it’ demonstrates the Derwent Living way. Looking at the Person Specification – The Derwent Living Way document, briefly outline how you show the following behaviours - professional, positive, accountable, honest, approachable, customer focussed, team workers and knowledgeable.

Disciplinary Have you been subject to a disciplinary hearing/penalty in the last 12 months? YES NO If yes, please give details:

Referees Please supply contact details for two people who are not related to you and are able to comment on your ability to meet the requirements of the job applied for. Current/most recent employer Name: Address: Postcode: Email address: Contact tel no: Working relationship to you: Previous employer Name: Address: Postcode: Email address: Contact tel no: Working relationship to you:

Are you related to any member of Derwent Living’s Board, staff or consultant/ contractor currently working for Derwent Living? YES NO If yes, please give details:

Declaration

By signing I agree that the information I have given is to the best of my knowledge, accurate and complete. I accept that deliberately providing false information or withholding facts may disqualify me for employment or render me liable to instant dismissal.

Signature: DATA PROTECTION ACT (1998) The data used on this form will be used by Derwent Living solely for the purposes of processing your application and will not be disclosed to any third parties. Diversity What is your Derwent Living believes that everyone ethnic group?: has a part to play, and everyone should White English/Welsh/Scottish/ have the opportunity to show what they Northern Irish/British Irish Gypsy or can do. We love the mix of ideas and Irish Traveller Any other White influences everyone brings. background, please detail below

This section is simply for our records, Mixed/multiple ethnic groups so we can be sure we’re doing the right White and Black Caribbean White and things – diversity information will not be Black African White and Asian Any provided to the recruiting manager. other mixed/multiple ethnic background, please detail below

Position applied for: Asian/Asian British Indian Pakistani Bangladeshi Where did you see this vacancy: Chinese Any other Asian background, please detail below

Religion: African/Caribbean/Black/

Black British Caribbean African Any other Any special requirements? African/Caribbean/Black background, please detail below

Age Please select your age range Other ethnic group 16-20 21-30 31-40 41-50 51-60 Arab Any other ethnic group, please 61-70 70+ detail below

Gender Eligibility to work in the UK Male Female Transgender Are you legally permitted to work in Sexuality the UK? YES NO Heterosexual Gay Lesbian Bisexual Rehabilitation of Disability Offenders Act (1974) Do you consider yourself to have a disability as defined by the Equality Act Some posts that involve unsupervised (2010)? access to children or vulnerable adults require a Criminal Records Bureau The Equality Act (2010) states a person Disclosure check. Where this is the has a disability if they have a physical case it will be clearly stated on the or mental impairment which has a advert and at interview. substantial and long-term adverse effect Do you have any convictions, which are on person’s ability to carry out normal not deemed as spent or are exempt day-to-day activities. from the Rehabilitation of Offenders Act YES NO (1974).

Ethnicity