Confidential Application For

CONFIDENTIAL APPLICATION FOR EMPLOYMENT

www.houghtonregis.org.uk [email protected] 01582 708540

Please return to: Houghton Regis Town Council, Peel Street, Houghton Regis, Beds LU5 5EY

JOB REF JOB TITLE APPLICANT REFERENCE

EMPLOYMENT RESTRICTIONS / REGULATIONS Please place an ‘X’ in the most appropriate boxes In accordance with the Immigration, Asylum and Nationality Act 2006 are you entitled YES NO to work in the UK?

If NO, please give details (or give details when any current work permit/visa is due to expire)

To the best of your knowledge are you related to any member of Staff or Councillor YES NO

DRIVERS DETAILS Please tick as appropriate Do you hold a full current driving licence? YES NO

Do you have access to a vehicle? YES NO RECRUITMENT INFORMATION Please advice of any dates you are NOT available for interview?

Where did you see this vacancy advertised?

PRESENT OR LAST EMPLOYMENT Dates Name of Present or Last Job Title Salary Notice Period From To Employer

Please supply a brief description of your main duties:

Please give your reason(s) for wanting to leave: EMPLOYMENT HISTORY Please list the most recent appointment first, in date order. Also provide details of any breaks in employment and the reason(s). Dates Name of Employer Job Title Reason(s) for Leaving From To

Brief Description of Main Duties

Dates Name of Employer Job Title Reason(s) for Leaving From To

If there have been any breaks in employment during the last five years please give reasons and dates:

PROFESSIONAL MEMBERSHIP Please give details of any professional membership you feel may be relevant to the person specification Professional Date By Exam Reg No Details Body Obtained (Yes/No)

QUALIFICATIONS/TRAINING/SCHOOL Please give details of any qualifications/training you feel may be relevant to the job description Qualifications/Training Event/Location or Institute Grades (if applicable) Year Obtained REASONS FOR APPLICATION In this section you are asked to outline how your knowledge, skills and experiences meet the Job Description. You should draw on you experiences from your current or previous roles or from other relevant situations (such as education, leisure or voluntary activities). Please refer to the evidence requirements on the Job Description.

. JOB REF JOB TITLE APPLICANT REFERENCE

ADDITIONAL PERSONAL DETAILS We display the “Two Ticks” symbol, which means we guarantee to interview all applicants with a disability who meet the essential criteria on the Job Description. Under the Disability Discrimination Act 1995, disability is described as a physical or mental impairment, which has substantial and long-term adverse effects on a person’s ability to carry out day to day activities

YOUR PERSONAL INFORMATION Title: Surname: Forenames: Preferred Name:

Address: Home:

Mobile:

Post Code: Email:

REFERENCES

Please supply details of two referees (who are not related to you and cover the last five years of employment), the first must be your present or last employer or if you are leaving education for the first time, your school / college / university tutor. Please indicate if your second referee is employment (preferable) or personal. Both referees should be able to comment upon your ability to meet the person specification criteria for the post that you are applying for.

First Referee Second Referee (Present or last manager or education tutor) Dates covered Name: Name: (Mr/Ms/Mrs) (Mr/Ms/Mrs) Position: Position:

Company: Company:

Address: Address:

Post Code: Post Code:

Telephone number: Telephone number:

Email address: Email address:

May we contact immediately? YES NO May we contact immediately? YES NO EQUALITY AND DIVERSITY MONITORING FORM This section of the application is purely for monitoring purposes and will be detached from your application. By completing this form you give Houghton Regis Town Council permission to collect, retain and process information about you. This information will only be used so that we can monitor our compliance with the law and best practice in areas such as equality of opportunity, non-discrimination, pay and benefits administration etc. JOB REF:

STATEMENT OF INTENT The Houghton Regis Town Council is committed to providing Equality of Opportunity for ALL by valuing difference and diversity, and is committed to achieving a balanced workforce in all areas of operation. By completing this form you will help us to continue our positive approach to equality and diversity.

PURPOSE Your ability to do the job is the only criteria for selection. The information on this page will be retained by the Clerk and used for statistical/ monitoring purposes only. None of the information will be seen by the short listing panel.

AGE PROFILE Please place an 'X' in the box which best describes your age Under 21 yrs 21- 30 yrs 31- 40 yrs 41- 50 yrs 51+ yrs Prefer not to say

GENDER Please select either male or female for your gender. Transgender or transsexual : Select the answer which you identify yourself as. You can select either ‘male’ or ‘female’, whichever you believe is correct, irrespective of the details recorded on your birth certificate. You do not need to have a Gender Recognition Certificate Male Female Transgender / Transsexual Prefer not to say

ETHNIC ORIGIN Ethnic Origin, as defined by the Race Relations Act 1976, describes a person by reference to their colour, race nationality, ethnic or national origin. Please choose ONE section, from A to E, and then mark the most appropriate box within the chosen section with an ‘X’ (the groups listed conform to the Commission for Race Equality recommendations) White Mixed Asian or Asian British British White and Black Caribbean Indian Irish White and Black African Pakistani Any other White White and Asian Bangladeshi background, please state: Any other Mixed background, Any other Asian background, please state: please state:

Black or Black British Chinese or other Ethnic Group Gypsy/Romany/Irish Traveler Caribbean Chinese Gypsy/Romany/Irish Traveler African Any other Ethnic Group, please state: Any other Black Prefer not to say background, please state: Prefer not to say

SEXUAL ORIENTATION Please place an 'X' in the box which best describes your sexual orientation Gay Man Gay Woman Prefer not to say Heterosexual/Straight Bisexual

RELIGIOUS BELIEF In the most recent UK Census the following religions were listed. Please place an 'X' in the box which most describes your religion, or add details of your religion if not listed below Christian (ALL) Buddhist Hindu Jewish Sikh Muslim No religion Prefer not to say Other religion(s), please state:

DISABILITY Please place an ‘X’ in the most appropriate boxes

The Disability Discrimination Act defines disability as 'a physical or mental impairment which has a substantial and long term adverse effect on a person's ability to carry out normal day to day activities'. In accordance with the Act do you regard yourself as someone with a disability?

Houghton Regis Town Council is an equal opportunities employer and is committed to the employment of people with disabilities. YES NO Prefer not to say

If YES, so that we can ensure that any appropriate arrangements are made to accommodate your disability if you are offered an interview, please give details of your disability:

MEDICAL INFORMATION/CONDITIONS Please place an ‘X’ in the most appropriate boxes Do you suffer from any illness which may affect your work? YES NO Prefer not to say If YES, please give details:

REHABILITATION OF OFFENDERS ACT 1974 Please place an ‘X’ in the most appropriate boxes

The Exception Order 1995 requires disclosure of ‘spent’ convictions if you are applying to work within Care or with Young People under the age of 18. Please note if an Enhanced Disclosure is required you are required to disclose YES NO ANY convictions, cautions or reprimands you may have, spent OR unspent.

Have you ever been convicted or cautioned for a criminal offence? If YES, please give details on a separate sheet.

DECLARATION By signing this form you declare that to the best of your knowledge the information you have given is correct. You understand that any false or misleading information together with withholding relevant information may lead to your application being disqualified, or the withdrawal of a job offer, or if you have been appointed, to your dismissal. SIGNED (or Print): DATED:

THANK YOU FOR COMPLETING THIS FORM

Please make sure that you complete the job reference on the application form.

We would like to thank you for your application and wish you every success, however if you have not heard from us within 4 weeks of the closing date, please assume that you have not been successful on this occasion.