<p> APPLICATION FOR A TEACHING APPOINTMENT</p><p>Surname (block capitals) Mr./Mrs./Ms.</p><p>Other names</p><p>Home address in full (block capitals)</p><p>Address for correspondence if different from above</p><p>Home telephone no.</p><p>Work telephone no.</p><p>Date of Birth Age</p><p>When could you take up duties if appointed?</p><p>Please return form to Ms Laura Wynne Head teacher Kingsbury Green Primary School Old Kenton Lane Kingsbury London NW9 9ND Please read carefully all instructions before completing this form. Please use BLACK ink, black ballpoint pen or typescript since it will be necessary to photocopy your application. Please complete in full. You may enclose a curriculum vitae for additional information, if you wish, but not as a substitute for filling in all sections of the form.</p><p>1. Name of school (if known)</p><p>2. Title of post</p><p>3. Primary Preferred age range</p><p>4. Secondary Subject</p><p>5. Standard Scale or Incentive Allowance (please state)</p><p>6. Closing date for completed form</p><p>7. Date of recognition as qualified teacher by the Department of Education DfE Number National Insurance Number Have you successfully completed a period With which authority? of probation? Date of completion of probation Do you need a work permit? </p><p>8. If you are applying for a job do you have a job share partner?</p><p>9. Please give dates on which you will not be available for interviews, e.g. holidays.</p><p>10. a) Are you suffering or have you suffered from an major illness/industrial injury? If yes, please specify.</p><p> b) Please state number of days you have been absent from work due to sickness in the past 12 months.</p><p> c) How many episodes of absence does this represent?</p><p> d) Is this your usual level of sickness?</p><p>11. Please give details of any superannuation scheme to which you belong</p><p>12. How did you hear of this job? (Please state the publication in which you saw it advertised) 13. Education </p><p>Secondary/Further Education (Where applicable please include details of examinations which have been or are about to be taken but results of which are not yet available.) If educated outside the European Economic Community please note that the School/Authority is required to confirm that you have acquired a standard in English and Mathematics which is equivalent to at least grade C at G.C.S.E Ordinary level. Please give details.</p><p>Name of school/college Subject and Qualifications Grade Date (from/to)</p><p>Higher Education/Teaching Qualifications</p><p>Name of college/university Subject and Qualifications Grade/Class Date (and address if outside U.K.) (if applicable) (from/to)</p><p>Other qualifications related to current or previous employment</p><p>Name of professional body Membership grade Was membership gained by Date examination</p><p>Relevant Inservice Courses</p><p>Course Qualifications gained Dates (if applicable) showing duration 14 Outside interests and activities/voluntary work</p><p>15 Employment history (include details of vacation employment if you are a college leaver). Please give full details as this section is used for salary assessment purposes.</p><p>Name and address of present Position/post From To Basic Other Total (or most recent) employer (month/year) (month/year) salary Allowances Remuneration</p><p>Name and address of previous Position (and Age range taught From To Reason for leaving employer (from most recent). allowance if (if applicable) (month/year) (month/year) Please state name of applicable) school/college if applicable 17 Please be sure to show how your education, training, experience and qualifications fit you for this post. (Refer to the Person Specification if applying for a particular vacancy.)</p><p>Please make full use of this section. (Attach additional sheets if necessary to provide further information in support of your application.) Shortlisting will be conducted only on the basis of written applications. It is therefore essential that all applicants, both internal and external, should complete this section of the application form. 18 Information for monitoring – All applicants are asked to complete this section; the information will enable us to monitor the effectiveness of our Equal Opportunities Policies. Please tick the appropriate spaces.</p><p>1. Ethnicity Asian Black White 01 Bangladeshi 06 African 09 Irish 02 Chinese 07 Caribbean 10 U.K. 03 Indian 08 Other (please specify) 11 Other (please specify) 04 Pakistani 05 Other (please specify)</p><p>2. Gender Male Female</p><p>3. Disabled Yes No Registered Disabled Yes No Registered Disabled Number</p><p>19 Referees. Please give the names of two people to whom reference can be made. One referee should normally be your current head teacher. Relatives may not be given as referees .</p><p>Referee 1 Referee 2 Name Name Occupation/status Occupation/status Address Address</p><p>Telephone No. Telephone No.</p><p>20 Voluntary Aided Schools (if applicable). Candidates for either Roman Catholic or Church of England Schools should give the address of the Parish Priest or Vicar as appropriate.</p><p>Name Status Address Telephone No.</p><p>21 Criminal convictions. By law, spent convictions must be disclosed. Please give details of any criminal convictions (not including minor traffic offences. If you do not have convictions, please write ‘NONE’.</p><p>22 Declaration. I hereby declare that I have understood and complied with the provisions concerning the disclosure of criminal convictions and I agree that the information given on this form may be used for registered purposes under the Data Protection Act, 1984. </p><p>Providing any misleading or false information to support your application or canvassing, directly or indirectly, anyone likely to be involved in the appointment process will disqualify you from any appointment or if appointed will render you liable to dismissal without notice.</p><p>23 Signature of applicant Date</p>