<p> Sublime 36 Brigadier Hill Enfield, Middlesex EN2 0NQ</p><p>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.</p><p>Role(‘s) Applied for? ______</p><p>1. Personal details (Please use block capitals)</p><p>Title (Mr/Mrs/Miss/other) ______</p><p>Full Name ______</p><p>Date of Birth ______</p><p>Marital Status ______</p><p>Nationality ______</p><p>National Insurance No ______</p><p>Place of Birth Town ______County ______</p><p>Country of Birth ______Nationality ______</p><p>Surname at Birth (if different) ______</p><p>Used until: Year ______</p><p>Any other Surname Used: ______</p><p>Used From ______To ______</p><p>Any other Surname Used: ______</p><p>Used From ______To ______</p><p>Email ______</p><p>Home Telephone Number ______</p><p>Mobile Telephone Number ______</p><p>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.</p><p>Passport Number ______</p><p>Start Date ____/_____/______Expiry Date ____/____/_____</p><p>Country of Issue ______2. Christian Life & Experience Driving Licence Number ______Please tell us how and when you became a Christian. Start Date ____/_____/______Expiry Date ____/____/_____</p><p>Address ______</p><p>______</p><p>Town ______City/Country ______Post Code ______</p><p>Since when have you lived at the above address : Month ______Year ______(If less than five years, please give previous address(es) with dates below)</p><p>From Month ______Year ______From Month ______Year ______</p><p>Address ______Address ______</p><p>______</p><p>Town ______Town ______</p><p>City/Country ______City/Country ______</p><p>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).</p><p>NB If the additional addresses do not cover more than five years, please provide details on the back page of this form.</p><p>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</p><p>Please give details of previous experience of looking after or working with young people and/or children, and any relevant training/qualifications.</p><p>Please tell us about any relevant qualifications or training you may have.</p><p>Are you prepared to undertake training?  YES  NO (tick as appropriate)</p><p>Have you ever had an offer to work with young people declined?  YES  NO (tick as appropriate). If yes, please give details.</p><p>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.</p><p>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.</p><p>Subject/s Grade/ Date Where obtained level</p><p>5. Employment Background Please give details of your employment history – beginning with your present/ most recent job</p><p>Employer Address Position held Dates</p><p>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).</p><p>Referee 1 ((Present / Most recent employer)</p><p>Name & Address ______</p><p>______</p><p>Tel No (day) ______Tel No (eve) ______E-mail ______</p><p>Referee 2 : (Present Pastor/ Church Leader/ Mentor)</p><p>Name & Address ______</p><p>______</p><p>Tel No (day) ______Tel No (eve) ______E-mail ______Do you wish to be contracted before these references are taken up? Yes/No</p><p>6. Declaration</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>If considered appropriate, do you agree to co-operate in obtaining a Criminal Records Bureau (CRB) Disclosure.  YES  NO (tick as appropriate). </p><p>I confirm that to the best of my knowledge, the information given on this form is true and accurate.</p><p>Signature ______</p><p>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</p><p>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 .</p><p> YES  NO</p><p>Charity No.: 1131280 Company No.: 06969145 V.A.T No.: 128 7979 56 Registered address: 69 Croyland Road , Edmonton, London N9 7BE 6</p>