1St Place Sure Start Children and Parents Centre

APPLICATION FORM FOR EMPLOYMENT (Please complete in black ink or type)

Post Applied for :

Reference No :

Return to:

Human Resources 1st Place Children & Parents’ Centre Chumleigh Street, Burgess Park, London SE5 0RN Email: [email protected] Tel: 020 7740 8070 Fax: 020 7703 1860

Your Details (please put in BLOCK CAPITALS) Title

Surname

Forenames

Address:

Telephone Home E-Mail

Telephone Work

Telephone Mobile National Insurance No:

updated 11/07 References

Please give details of two people able to provide references relating to your experience and suitability to this post. The first referee should be your current or most recent employer. Friends or family may not be submitted for referees.

References will be collected prior to interviews as part of the safer recruitment process

Referee 1 Referee 2 Name Name Position Position Address Address

Postcode Postcode Tel No Fax: Tel No Fax: Email Email

Education and Training Give details of Secondary Schools, Colleges, Universities or Institute of Further Education attended.

(You may be required to produce evidence of your qualification on appointment) Name/Nature Of Establishment Qualifications Gained Period (School, university, college etc.) (Give details, including dates of any (List dates starting with educational Certificates, the most recent) Professional or other qualifications and training with standard obtained, if applicable) From To

Full title of any professional body of which you are a member and state length of membership

updated 11/07 Training Courses (Please provide details by attaching a separate sheet listing any other relevant qualifications or courses attended (include non-certificate courses)

Experience, Skills & Interests Please list any additional skills or training you feel is relevant to this post

Any Professional / Qualification Training currently in process?

Current or Last Employer

Job Title

Name of Employer

Address of Employer

Post Code Telephone Number

Dates employed from To

Reason for leaving:

Brief summary of duties:

Previous Employment History (for past 10 years starting with most recent) Please use this section to outline in date order (starting with the most recent) details of your paid employment, volunteering activities and any other relevant activities. Where you have been employed by an agency outline the details of the agency as well as the placement(s). If there are any gaps in the information you give below please ensure you clearly identify the dates and provide information that clarifies the situation (e.g. education, travelling and unemployment). We reserve the right to approach any of your previous employers.

Position held & principle Name & Address of From To Reason for leaving duties performed Employer

updated 11/07 Continue on separate sheet if necessary

Please explain any gaps in your employment history and give reasons

Statement in Support

Please outline below why you are interested in this post, and describe how your skills, knowledge & experience are applicable (please address each item of the Person Specification in order, noting the number you are addressing).

updated 11/07 Attach additional A4 sheet if necessary.

Are there any dates you would not be able to attend for interview?

Declaration

The details given on this application are correct to my knowledge and belief. I understand that my application may be rejected or that I may be dismissed for withholding relevant details or giving false information. By signing and returning this application form, I consent to the employer using and keeping information about me provided by me or by third parties such as referees relating to my application or future employment. Such information includes details relating to my health and to any criminal record.

This form was completed by:……………………………………………………. (Print Name)

Applicant Signature: …………………………………………..

Date: …………………………..

updated 11/07

POSITIVE ABOUT DISABLED PEOPLE

1st Place is positive about employing people with disabilities and will make reasonable adjustments to enable full participation in the selection process and in employment with us. The following questions are designed to enable us to best support applicants with disabilities. If you are disabled you are guaranteed an interview if you meet the minimum requirements for the post. Note - You must say that you require this consideration on your statement in support, as this monitoring form is not included in the short listing process.

ADDITIONAL REQUIREMENTS

Do you have any medical condition or disability that you believe we should be aware of:

(a) In relation to adjustments you may need us to make to enable you to participate in the recruitment process (interviews and tests?)

Yes  No  (if yes, please give details)

(b) In relation to your employment and for which you may require support, modifications, adjustments, or special equipment to assist you in carrying out the duties of this post?

Yes  No  (if yes, please give details)

Do You Require A Work Permit? Yes  No  If Yes, Please provide further details

Post applied for

Forename

Surname

Signed

updated 11/07 DISCLOSURE OF INFORMATION

Are you related to any members of the board or to an employee? Yes / No If yes, please give details:

Have you ever been dismissed from any employment? Yes / No

REHABILITATION OF OFFENDERS ACT 1974

I confirm that to the best of my knowledge the details given are correct. I understand that the post applied for is NOT protected by the Rehabilitation of Offenders Act 1974 and that I must disclose information about all criminal convictions (if any), no matter when they occurred. In the event of employment, failure to disclose all previous convictions, even is they are ‘spent’ could result in disciplinary action, including dismissal. (All information is confidential and will be considered only if relevant to the post you have applied for)

Have you ever convicted of a criminal offence? Yes / No

If Yes please provide details of convictions or sentence on a separate sheet

PROFESSIONAL REGISTRATION DECLARATION

Have you been or are you currently subject to fitness to practice proceedings by an appropriate licensing or regulatory body in the UK or any other country? Yes / No

If yes, please provide on a separate sheet details of the nature of proceedings undertaken, or contemplated, including dates of proceedings, country where proceedings were undertaken and the name of the licensing or regulatory body concerned.

IMPORTANT NOTE - DECLARATION

I declare that the information given on this form is true and complete. I understand that any false information included could lead to disciplinary action which may result in dismissal. Signed Date

Post applied for

Forename

Surname

Signed

updated 11/07 EQUAL OPPORTUNITIES POLICY

1st Place Children and Parents’ Centre is committed to ensuring that no job applicant or employee receives less favourable treatment that others on grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex, sexual orientation or is disadvantaged by any conditions or requirements which cannot be shown to be justifiable.

MONITORING In order to help us ensure that our Equal Opportunities policy is being carried out, we would be grateful if you could complete all parts of this page. This information is confidential and used solely by the Human Resources Department for monitoring purposes. It is not used as part of the selection process.

Please tick the description which you feel is the most appropriate

1. Male Female

2. Please choose ONE section from A to F below and then tick the most appropriate box (one box only)

A WHITE B MIXED British White & Black Caribbean Irish White & Black African Other (please write in) ______White & Asian Other (please write in)  ______C ASIAN OR ASIAN BRITISH Indian D BLACK OR BLACK BRITISH Pakistani Caribbean Bangladeshi African Other (please write in) ______Other (please write in) ______

E CHINESE F ANY OTHER BACKGROUND Chinese Any other background Other (please write in) ______Other (please write in) ______

updated 11/07