The N:Flame Trust

Sublime 36 Brigadier Hill Enfield, Middlesex EN2 0NQ

Tel: 0203 012 0059 Web: www.sublime.uk.com E-mail: [email protected] Sublime Worker Application Form We ask all prospective workers with children to complete this form. If there is insufficient room to answer any question, please continue on a separate sheet. Information provided will be kept confidentially by Sublime, unless requested by an appropriate authority.

Role(‘s) Applied for? ______

1. Personal details (Please use block capitals)

Title (Mr/Mrs/Miss/other) ______

Full Name ______

Date of Birth ______

Marital Status ______

Nationality ______

National Insurance No ______

Place of Birth Town ______County ______

Country of Birth ______Nationality ______

Surname at Birth (if different) ______

Used until: Year ______

Any other Surname Used: ______

Used From ______To ______

Any other Surname Used: ______

Used From ______To ______

Email ______

Home Telephone Number ______

Mobile Telephone Number ______

Charity No.: 1131280 Company No.: 06969145 V.A.T No.: 128 7979 56 Registered address: 69 Croyland Road , Edmonton, London N9 7BE 1 1b. Personal Details cont.

Passport Number ______

Start Date ____/_____/______Expiry Date ____/____/_____

Country of Issue ______2. Christian Life & Experience Driving Licence Number ______Please tell us how and when you became a Christian. Start Date ____/_____/______Expiry Date ____/____/_____

Address ______

______

Town ______City/Country ______Post Code ______

Since when have you lived at the above address : Month ______Year ______(If less than five years, please give previous address(es) with dates below)

From Month ______Year ______From Month ______Year ______

Address ______Address ______

______

Town ______Town ______

City/Country ______City/Country ______

PleasePost tell Code us about your______Christian experience (i.e. with church(es)Post you Code have attended______and dates, name of minister/leader, any activities you have undertaken and any other Christian service).

NB If the additional addresses do not cover more than five years, please provide details on the back page of this form.

Charity No.: 1131280 Company No.: 06969145 V.A.T No.: 128 7979 56 Registered address: 69 Croyland Road , Edmonton, London N9 7BE 2 3. Working with Children/Young People – If applicable for role

Please give details of previous experience of looking after or working with young people and/or children, and any relevant training/qualifications.

Please tell us about any relevant qualifications or training you may have.

Are you prepared to undertake training?  YES  NO (tick as appropriate)

Have you ever had an offer to work with young people declined?  YES  NO (tick as appropriate). If yes, please give details.

Do you suffer or have you suffered from any illness which may directly affect your work with young people?  YES  NO (tick as appropriate). If yes, please give details.

Charity No.: 1131280 Company No.: 06969145 V.A.T No.: 128 7979 56 Registered address: 69 Croyland Road , Edmonton, London N9 7BE 3 4. Education Please list academic, professional and other qualifications with dates and grades gained, including GCSE’s / O levels.

Subject/s Grade/ Date Where obtained level

5. Employment Background Please give details of your employment history – beginning with your present/ most recent job

Employer Address Position held Dates

Charity No.: 1131280 Company No.: 06969145 V.A.T No.: 128 7979 56 Registered address: 69 Croyland Road , Edmonton, London N9 7BE 4 5. References Please give the names, addresses and telephone numbers of two referees: (These will only be used if shortlisted).

Referee 1 ((Present / Most recent employer)

Name & Address ______

______

Tel No (day) ______Tel No (eve) ______E-mail ______

Referee 2 : (Present Pastor/ Church Leader/ Mentor)

Name & Address ______

______

Tel No (day) ______Tel No (eve) ______E-mail ______Do you wish to be contracted before these references are taken up? Yes/No

6. Declaration

Because of the nature of the work for which you are volunteering it is exempt from the provision of section 4(ii) of the Rehabilitation of Offenders Act 1974 (Exemptions Order 1975), and you are therefore not entitled to withhold information about convictions which for other purposes are “spent” under the Provisions of the Act and in the event of an appointment, any failure to disclose such convictions could result in the termination of your contract with Sublime.

Have you been charged with or convicted of a criminal offence, or are you at present the subject of criminal investigations? (NB the disclosure of an offence may not prohibit your appointment) YES  NO (tick as appropriate). If yes, please give the nature of the offence(s) and dates.

Have you ever been involved in court proceedings concerning a child for whom you have parental responsibility?  YES NO (tick as appropriate). If yes, please give details.

Charity No.: 1131280 Company No.: 06969145 V.A.T No.: 128 7979 56 Registered address: 69 Croyland Road , Edmonton, London N9 7BE 5 To your knowledge have you ever had any allegation made against you which has been reported to, and investigated by, Social Services and/or the Police?  YES  NO (tick as appropriate). If yes, we may need to discuss this with you.

If considered appropriate, do you agree to co-operate in obtaining a Criminal Records Bureau (CRB) Disclosure.  YES  NO (tick as appropriate).

I confirm that to the best of my knowledge, the information given on this form is true and accurate.

Signature ______

Date ______Has there ever been cause for concern regarding your conduct with children?  YES  NO (tick as appropriate). If yes, please give details. CV or Personal Statement

You many attach a separate your CV or personal statement to this form. In a personal statement on no more than two sides of A4 paper, please describe your motivation and reasons for applying for this role. Outline how you meet the required skills and experiences for this position, as outlined in the job description and person specification. I confirm that I have read, understood and agree to adhere to Sublime’s Safeguarding Policy .

 YES  NO

Charity No.: 1131280 Company No.: 06969145 V.A.T No.: 128 7979 56 Registered address: 69 Croyland Road , Edmonton, London N9 7BE 6