<p>HR FORM: Part A Employment Application Extern is an Equal Opportunities Employer</p><p>For Office Use Only Job Reference No ROI733/07/15 Applicant Reference No Date Received</p><p>Part A Application for the post:</p><p>Service Co-ordinator: Janus SWHB (Cherry Orchard)</p><p>NB. Both Part A - E of this application form MUST be completed by the applicant before this application can be considered. Part F is for guidance purposes only. Applications are accepted in good faith.</p><p>Applications must be received by on or before the closing date.</p><p>LATE APPLICATIONS WILL NOT BE ACCEPTED</p><p>Extern is committed to protecting futures including the future of the environment, as such all applications must be received through e-mail at [email protected]</p><p>If you are unable to e-mail your form, please contact HR Services at: Extern HQ Hydepark House 3 McKinney Road Newtownabbey BT36 4PE, Northern Ireland T: 028 9084 0555 F: 028 9084 7333 </p><p> in order to facilitate receipt of your application.</p><p>Part A and Part B will be made available to the short-listing and interviewing panel</p><p>Extern reserves the right to reasonably alter criteria.</p><p>1 of 14 (Application Form Under Review; InterimApproval By GC April 2011) 1.Personal Details</p><p>Title Surname</p><p>Forename(s) Former Surname(s) (underline name you are known by) (if any)</p><p>Address for Communication</p><p>Postcode</p><p>Email</p><p>Daytime Telephone No. (including STD code) Mobile</p><p>Permanent Address (if different from above) Postcode</p><p>Town of Birth Country of Birth</p><p>Current Nationality National Insurance No.</p><p>2. Educational Qualifications Please insert details of your second level education</p><p>Dates of School Title of qualification Subject and Grades Awarded attendance</p><p>2 of 14 (Application Form Under Review; InterimApproval By GC April 2011) 3. University or other further education</p><p>If you have attended university or college, please provide details as follows:</p><p>First degree (or other third level qualification)</p><p>Date Class University or Dates of Title of Type of degree, Main subjects awarded/e or college attendance qualification diploma or certificate xpected division</p><p>4. Post-graduate qualifications</p><p>Date Class University or Dates of Title of Type of degree, Main subjects awarded/e or college attendance qualification diploma or certificate xpected division</p><p>Research or Study</p><p>Examination certificates relating to the above must not be sent with this application, but the original certificates (not copies) may be required should you be successful beyond the interview stage.</p><p>5. Professional / Vocational qualifications If you have any professional / vocational qualifications and/or are a member of any professional body please provide details as follows:-</p><p>Grade of Membership and Membership Professional bodies of which you are a member No.</p><p>3 of 14 (Application Form Under Review; InterimApproval By GC April 2011) 6. Career History Please detail below all your employment/self-employment/voluntary work relevant to this application. Start with your present/most recent employment providing clear details of any gaps in employment. Show the name of the employer (or name of company, if self- employed), job title(s), main duties and responsibilities and dates of employment.</p><p>Current Name and Address of Job Title(s) Salary/Salary From To most recent Employer Grade/Position on leaving Month Year Month Year</p><p>Main Duties and Responsibilities of Post(s)</p><p>Previous Experience (Please list your previous posts beginning with the most recent.)</p><p>Main Duties From To Employer Grade/Position and Responsibilities Month Year Month Year</p><p>4 of 14 (Application Form Under Review; InterimApproval By GC April 2011) HR FORM: Part B Employment Application Extern is an Equal Opportunities Employer</p><p>Part B</p><p>The objective is to record succinctly how you have the experience and qualities sought.</p><p>ALL of the “Experience and Qualities Sought” section of this form will be available to the shortlisting and interview panels.</p><p>Experience and Qualities Sought</p><p>Please complete all sections. (CVs or other supplementary material will not be considered).</p><p>Extern may decide to interview only those applicants who appear to them, from the information available, to be the most suitable in terms of relevant experience and ability. It is therefore essential that you fully describe in each of the following sections how you meet the particular experience and qualities sought, giving examples and specifying exact dates as appropriate. </p><p>Please read all sections of the Person Specification. This part of the application asks you to describe your experience, skills and personal qualities which are applicable to the post. In completing your application you are advised to make clear reference as to how you meet with to the essential and desirable criteria for the relevant role. It is not appropriate to simply list the various posts that you have held. Extern will not make assumptions from the title of the post as to the skills and experience you have gained.</p><p>(Extern reserves the right to enhance or decrease the criteria depending on the quality and number of applications.)</p><p>1. Please state clearly how you meet with the essential criteria and essential key attributes.</p><p>ESSENTIAL QUALIFICATIONS & EXPERIENCE:</p><p>5 of 14 (Application Form Under Review; InterimApproval By GC April 2011) 2. Please state clearly how you meet with the desirable criteria.</p><p>ADDITIONAL DESIRABLE QUALIFICATIONS & EXPERIENCE:</p><p>3. Please provide any additional information which you wish to give in support of your application.</p><p>4. Other Information</p><p>IF APPOINTED, HOW MUCH NOTICE WOULD YOU REQUIRE BEFORE TAKING UP APPOINTMENT?</p><p>5. References</p><p>Please note that three references will be required for an appointment following your interview including that of a present/most recent employer’s. </p><p>Name/Title and contact details of person from whom reference should be sought:-</p><p>Referee 1 Referee 2 Referee 3 Name Name Name</p><p>Job Title Job Title Job Title</p><p>Contact Details Contact Details Contact Details Address Address Address</p><p>6 of 14 (Application Form Under Review; InterimApproval By GC April 2011) Tel No. Tel No. Tel No.</p><p>Email Email Email</p><p>Health Declaration</p><p>Following the introduction of the Employment Equality Acts 1998 to 2008 and Equal Status Acts 2000 to 2008, employers must ensure that employment practices are not discriminatory and that reasonable adjustments are made to the workplace to overcome the effects of disability. In order to help us in this process, applicants must provide the following information, but in doing so should also be aware that answering “yes” to any of the following questions does not necessarily exclude them from the competition, but may require them to provide further information.</p><p>1.Do you suffer from any medical condition or disability which:</p><p>(a) may prevent your regular attendance at work, or your ability to give effective service over a period of up to one year?</p><p>Yes______No ______</p><p>(b) may have health and safety implication for carrying out the job for which you are being considered, e.g. fits, fainting attacks, blackouts or epilepsy</p><p>Yes______No ______</p><p>2. If yes, please give details:</p><p>3. Do you suffer from any medical condition or disability which you would like the employer to take into account when considering your application?</p><p>Yes______No ______</p><p>If yes, please give details:</p><p>ATTENDANCE AT INTERVIEW</p><p>Disability is defined as “any physical or mental impairment which has a substantial and long-term effect on a person’s ability to carry out normal day-to-day activities and which has lasted or is likely to last for more than 12 months”.</p><p>Do you consider that you have a disability? Yes No If so, do you require any arrangements to assist you if called Yes No for interview? Please provide details of assistance required if applicable:</p><p>7 of 14 (Application Form Under Review; InterimApproval By GC April 2011) HR FORM: Part C </p><p>For Office Use Only Job Reference No ROI733/07/15 Applicant Reference No Date Received</p><p>1. Criminal Convictions Have you ever been convicted of a criminal offence or are there any charges outstanding?</p><p>Yes No</p><p>If so, please give full details. You need not include motoring convictions unless your driving licence has a current endorsement as a result, and you need not include convictions which are “spent” under the Table of Rehabilitation Periods </p><p>HR FORM: Part D Employment Application: Equal Opportunities Monitoring Form An Equal Opportunities Employer</p><p>For Office Use Only Job Reference No ROI733/07/15 Applicant Reference No Date Received</p><p>8 of 14 (Application Form Under Review; InterimApproval By GC April 2011) PLEASE ENSURE THAT YOU COMPLETE THIS EQUAL OPPORTUNITIES MONITORING FORM</p><p>Access to this information will be strictly controlled in accordance with the Data Protection Act 1998 and Data Protection (Amendment) Act 2003 and will not be available to those considering your application for employment. Monitoring will involve the use of statistical summaries of information in which the identities of individuals will not appear. The information will not be available for any purpose other than equal opportunities monitoring.</p><p>Extern is fully committed to supporting the elimination of all forms of discrimination in employment and to using its services to help secure the objectives of fair employment, equal opportunity and good relations. </p><p>Extern selects those suitable for appointment solely on the basis of merit without regard to an individual’s religious belief, gender, disability, race, political opinion, age, marital status, sexual orientation or whether or not they have dependants.</p><p>DATE OF BIRTH</p><p>Please tick the appropriate box</p><p>GENDER</p><p>Are you Male Female</p><p>MARITAL STATUS</p><p>Are you Married Single Divorced Separated Other</p><p>HAVE YOU ANY CARING RESPONSIBILITY?</p><p>Children Relative(s) Other None</p><p>RACE The Employment Equality Acts 1998 to 2008 and Equal Status Acts 2000 to 2008 make it unlawful to discriminate in employment on grounds of colour, race, nationality or ethnic or national origins. This information is gathered in accordance with Data Protection Act 1998 and Data Protection (Amendment) Act 2003, and best practice, It will be used only for monitoring the effectiveness of the Agency’s equal opportunity policy and to comply with obligations relating to monitoring, investigations or proceeding under the requirements of the Employment Equality Acts 1998 to 2008 and Equal Status Acts 2000 to 2008.</p><p>Please tick appropriate box Are You</p><p>White Of Black African Origin</p><p>Of Black Caribbean Origin Of Bangladeshi Origin</p><p>Of Chinese Origin Of Indian Origin</p><p>Of Other Origin (please specify) Of Pakistani Origin</p><p>Are you a member of a mixed ethnic group? YES NO</p><p>Are you a member of the Irish Traveller Community? YES NO 9 of 14 (Application Form Under Review; InterimApproval By GC April 2011) DISABILITY (Please refer to Guidance Notes before completing this section of the Monitoring Form)</p><p>The Employment Equality Acts 1998 to 2008 and Equal Status Acts 2000 to 2008 make it unlawful for an employer to treat a disabled person less favourably than someone else because of their disability, unless there is a good reason.</p><p>Do you consider yourself to have a disability? YES NO</p><p>Under the Disability Discrimination Act 1995, disability is defined as: “A physical or mental impairment which has a substantial and long-term effect on a person’s ability to carry out normal day-to-day activities”.</p><p>Using this definition do you consider yourself to have a YES NO disability?</p><p>If you have answered “no” please ignore the remaining questions in this section. If you have answered “yes” please complete the remaining section.</p><p>Hearing Impairment Reduced Physical Capacity</p><p>Visual Impairment Severe Disfigurement</p><p>Speech Impairment Learning Difficulties</p><p>Mobility Impairment Mental Illness/Mental Health Difficulty</p><p>Physical Co-ordination Difficulties</p><p>Declaration: Part E </p><p>For Office Use Only Job Reference No ROI733/07/15 Applicant Reference No Date Received</p><p>1.Warning</p><p>Only applications that contain all the requested information including the Equal Opportunities Monitoring Form (Section 14) will be considered. Information in support of your application will not be accepted after the closing date for receipt of applications.</p><p>10 of 14 (Application Form Under Review; InterimApproval By GC April 2011) Before you submit your application, please ensure that you are eligible for this competition by referring to the job description and personnel specification.</p><p>Any attempt on the part of a candidate to enlist support for his/her application through any person, except as referee to be named by him/her in the application form, will disqualify him/her from consideration.</p><p>A candidate found to have given false information or wilfully to have suppressed any material fact will be liable to either disqualification or, if appointed, to dismissal.</p><p>Late applications will not be accepted.</p><p>2.Declaration</p><p>The particulars given by me in this application are true and accurate to the best of my knowledge and belief. I understand that in the event that I have given false information or wilfully suppressed any material fact in this application that I am liable to either disqualification or, if appointed, to dismissal.</p><p>My electronic signature provides the authority of the original.</p><p>Signed Date</p><p>11 of 14 (Application Form Under Review; InterimApproval By GC April 2011) HR FORM: Part F Employment Application: Guidance Notes An Equal Opportunities Employer</p><p>Guidance Notes in Completing the Disability section of your equal opportunities monitoring form - (please ensure you read this section carefully before completing your application form).</p><p>INFORMATION FOR APPLICANTS</p><p>The Employment Equality Acts 1998 to 2008 and Equal Status Acts 2000 to 2008 support the rights of disabled people. The Acts make it unlawful to discriminate against disabled people and require employers to make what are referred to as “reasonable adjustments” to prevent disadvantage to a disabled person at work. Such adjustments may, where practical, range from modification to premises through to changes in working arrangements or the provision of special equipment. </p><p>The Acts define disability as </p><p> i) The total or partial absence of bodily or mental functions, including the absence of a part of a person’s body; ii) The presence in the body of organisms causing, or likely to cause, chronic disease or illness; iii) The malfunction, malformation or disfigurement of a part of a person’s body; iv) A condition or malfunction that results in a person learning differently from a person without the condition or malfunction; or v) A condition, illness or disease that affects a person’s thought processes, perception of reality, emotions or judgement or that results in disturbed behaviour; and shall be taken to include a disability that exists at present, or that previously existed but no longer exists, or that may exist in the future or that is imputed to a person.</p><p>Apart from the use of spectacles or contact lenses to correct sight, the effect of treatment or correction on an impairment should be ignored. For example, in the case of someone with diabetes, whether or not the effect is substantial will depend on what the condition would be if he or she was not taking medication.</p><p>The guidance which follows contains examples of conditions which might give rise to particular categories of disability. You may feel that the suggested category is inappropriate in your case. For example, you may have a condition which is shown here as being likely to give rise to physical co-ordination difficulties, whereas in your opinion the resultant disability is more appropriately described under reduced physical capacity. In such cases you should choose the category which seems most suitable to you.</p><p>Hearing impairment: </p><p>12 of 14 (Application Form Under Review; InterimApproval By GC April 2011) For example, being deaf or hard of hearing. If you wear a hearing aid which brings your level on a par with the average you are still considered to have a disability.</p><p>Visual impairment: For example, being registered blind or partially sighted. If your sight is corrected by the use of spectacles or contact lenses this is not considered a disability.</p><p>Speech impairment: For example, being unable to speak, or having difficulty in speaking.</p><p>Mobility impairment: For example, being able to walk only limited distances; having difficulty walking other than slowly or with unsteady or jerky movements; having difficulty sitting, standing, bending or reaching; having difficulty climbing stairs, or using a normal means of transport; needing to use a walking stick, crutches or wheelchair.</p><p>Physical co-ordination difficulties: This relates to balanced and effective interaction of body movement, including hand and eye co-ordination, and might include, for example, problems of manual dexterity and of muscular control, e.g. incontinence, epilepsy, Parkinson’s disease.</p><p>Reduced physical capacity: This includes debilitating pain and lack of strength, breath, energy or stamina, such as might arise, for example, from cardiovascular conditions, asthma, diabetes. It may also result from progressive conditions, eg muscular dystrophy, cancer, multiple sclerosis, HIV/AIDS. </p><p>Severe disfigurement: Examples of disfigurements include scars, birthmarks, limb or postural deformation or diseases of the skin. A tattoo is not considered as a severe disfigurement.</p><p>Learning difficulties: For example, reading or writing with difficulty. Includes the mental inability to perceive physical danger.</p><p>Mental illness: For example, having schizophrenia, clinical depression, severe phobias.</p><p>TABLE OF REHABILITATION PERIODS</p><p>The table below outlines the rehabilitation periods after which many of these sentences will be considered “spent”. This means you are able to answer “no” if you are asked about a criminal conviction or record - unless the job being applied for is an “excepted” one. The job to which this application form relates is not an “excepted” one.</p><p>Custodial sentences of over 2.5 years can never become spent.</p><p>13 of 14 (Application Form Under Review; InterimApproval By GC April 2011) Rehabilitation Period</p><p>Aged 17 Aged or Over under 17 Upon Upon Conviction Conviction</p><p>Prison (immediate or suspended sentence) or young offender institution: 10 years 5 years more than 6 months but less than 2.5 years</p><p>Prison (immediate or suspended sentence) or young offender institution: 7 years 3.5 years 6 months or less</p><p>Fine or community service order 5 years 2.5 years</p><p>Absolute discharge 6 months 6 months</p><p>Probation, supervision, care-order, 1 year or until order expires conditional discharge or bind-over (whichever is longer)</p><p>Attendance Centre Order 1 year after the Order expires</p><p>Hospital Order (with or without 5 years or 2 years after the order restriction) expires (whichever is longer)</p><p>*End</p><p>14 of 14 (Application Form Under Review; InterimApproval By GC April 2011)</p>