Monitoring form number

Application for Employment - Disclosure required

1. Vacancy details

Post for which you are applying:

Directorate:	Applicant ID:

Job ref:	Closing Date:

Please return this form directly to the school via: Email: or Address:

If you would like an acknowledgement of your application, please request this in your email, or attach a self addressed envelope.

2.  Personal details

Family name:	Initials:	
		
Home Address:	Telephone Work:	
	Home:	
	Mobile number:	
Postcode:		
NI number:	Email address:	

Guidance Notes & Data Protection Act

•	Please note that we do not accept CVs (curriculum vitae). 

•	We will decide whether to invite you for interview on the basis of information given by you on this application form. 
•	When you sign and return this form, you are giving us permission to process and hold on computer, the information or data you have supplied or referred to on it, including any information that you may consider to be sensitive and personal. 
•	This information will also be held on your personal file, if you are appointed. 
•	The data may be used by Shropshire Council for the purposes of equality monitoring, compiling statistics and maintaining other employment records. 

3. Present employment  (If you are currently unemployed please leave blank)

Job title:	Basic pay/grade:

Employer's name:	Other pay:

Address:	Date started:

Period of notice:

Telephone number:

Postcode:	May we contact you on this number?

Are you registered with the General Teaching Council/GSCC:

Outline of duties and responsibilities:

Continue on a separate sheet if necessary, placing your initials and job reference at the top.

4. Driving

Do you have a full current driving licence? If YES, type of licence?

Do you have a vehicle available for work purposes?

5. Previous employment

•	Please list all of your previous jobs including any with your present employer. Include all local government and related service. Start with the most recent. 

•	References may be sought from your previous employers. 

Job title:	Date started:	
Employer’s name:	Date left:	
Address:	Postcode:	
Brief outline of duties:		
Reason for leaving:		
		
Job title:	Date started:	
Employer’s name:	Date left:	
Address:	Postcode:	
Brief outline of duties:		
Reason for leaving:		
		
Job title:	Date started:	
Employer’s name:	Date left:	
Address:	Postcode:	
Brief outline of duties:		
Reason for leaving:		
		
Job title:	Date started:	
Employer’s name:	Date left:	
Address:	Postcode:	
Brief outline of duties:		
Reason for leaving:		
		
Job title:	Date started:	
Employer’s name:	Date left:	
Address:	Postcode:	
Brief outline of duties:		
Reason for leaving:		
		
Job title:	Date started:	
Employer’s name:	Date left:	
Address:	Postcode:	
Brief outline of duties:		
Reason for leaving:		

Job title:	Date started:	
Employer’s name:	Date left:	
Address:	Postcode:	
Brief outline of duties:		
Reason for leaving:		
		
Job title:	Date started:	
Employer’s name:	Date left:	
Address:	Postcode:	
Brief outline of duties:		
Reason for leaving:		

Continue on a separate sheet if necessary, placing your initials and job reference at the top.

6. Breaks in employment history since leaving school (Completion is mandatory)

Any gaps in employment history since leaving school and reasons must be detailed below; this should include voluntary work, unemployment, domestic reasons, prison custody etc.

From:	To:	Reason:

From:	To:	Reason:

From:	To:	Reason:

From:	To:	Reason:

From:	To:	Reason:

7. Training

Please list below relevant job-related training you have undertaken, and/or any professional qualifications achieved. Continue on a separate sheet if necessary.

Office use only.
Date	Course title	Organiser	Length  Certificates
checked by:

8. Educational qualifications

Please give details of secondary, further and higher education qualifications achieved. Start with the most recent. Continue on a separate sheet if necessary.
	Date	Institute details (eg College etc).	Grade	Office use only.		
		Qualification gained or pending, and subject	obtained	Certificates		
				checked by:		

9. Languages (Please detail below if you have any language ability other than English)

Able to effectively converse and read:

Able to converse, read and write:

Totally fluent:

10. Membership of professional bodies (Please state whether by election, exemption or examination)

Office use only.
Date	Professional Body	Membership no.  Grade/Level  Certificates
checked by:

11. Further details

•	Please give any information which you think will help us to consider your application, including relevant experience (voluntary or work), skills, abilities and any specialist knowledge you have. 

•	You should try to relate your information to the job description and person specification for the post you are applying for. 

You may submit additional sheets as necessary, placing your inititals, surname and job reference at the top of the page.

12. Disciplinary matters

Have you been subject to any disciplinary investigation or action including suspension from duty during your periods of employment with any employer? Include any investigations or actions taken by your professional body. Both Spent or Unspent matters need to be disclosed.

If YES, please provide details below of action taken including dates. Include any pending incident/action.

13. Relationship to council members or employees

Please give the details of any elected member or employee of the Council to whom you are related. If you fail to disclose such information you may be disqualified from consideration or, if appointed, liable to dismissal. Canvassing of any councillor or senior officer will disqualify a candidate for appointment.

Name:	Relationship:

14.	Criminal Convictions / Cautions / Disqualified Persons / Investigations 

•	“Shropshire Council regards as paramount the welfare and safety of vulnerable adults & children. Whilst criminal convictions are not necessarily a bar, this safety consideration will be key to all decisions regarding the employment of staff, approval of carers or volunteers and standards of external contractors.” 

•	This position is exempt under the Rehabilitation of Offenders Act 1974. 

•	“It is within this context, and the following guidelines, that decisions will be made in relation to applicants who have any form of criminal conviction or who are included on the ISA Barred List.” 

•	To assist with the implementation of this policy, all applicants are asked to complete the following questionnaire and provide written consent for checks to be completed. 

1.	Have you ever been convicted of a criminal offence or received a police caution, reprimand or warning? 

(If the answer is YES, please provide the details in section 16.)

2.	Have you ever received a final written warning or been dismissed from your current or any previous employment (other than in a redundancy situation?) 

(If the answer is YES, please provide the details in section 12.) 3. Has your name been added to the ISA Barred List.
(If the answer is YES, please give details below)

4.	Have you ever been subject to any legal proceedings involving any social services authority or it’s equivalent, here or abroad, that has resulted in the removal of children or vulnerable adults from your care, or the imposition of a statutory supervision order? 

(If the answer is YES, please give details below)

5.	Have you or any person with whom you reside with ever been refused registration or cancelled from an official register of: 

•	Child-minders; 
•	Day Care Providers; 
•	Private Fostering; 
•	Registered Care Home or Children’s Home? 

(If the answer is YES, please give details in section 16.)

(Applicants are reminded that knowingly withholding this information, or failing to disclose subsequent information is likely to lead to immediate suspension or termination of employment or approval).

Further, applicants should note that it is a criminal offence to knowingly apply for, offer to do, accept or do any work with children when prevented either:

a)	by reason of disqualification order under the Criminal Justice and Court Services Act 2000 

b)	by reason of inclusion on the ISA Barred List. 

I hereby give consent to the local authority completing such checks as are necessary with records held by the authority and/or other agencies in order to verify the information provided above.

I further understand and agree that if, for whatever reason, my application is either refused or withdrawn, but information is revealed which leads the Council to conclude that I may pose a risk to children and/or vulnerable adults, it will keep this information for an appropriate period.

I understand that the Council will not reveal this information to any other organisation or individual outside of the Council, unless it is asked a direct question about me or circumstances suggest that the protection of a child or children or vulnerable adult require immediate disclosure. I understand that, if practicable, I will be alerted to such possible disclosure and be invited to comment.

Name:	Position applied for:

Signed:	Date:

15.	If you answered YES to any of the questions in section 15, please give further details below 

This post is exempt under the Rehabilitation of Offenders Act and a Criminal Records Bureau Disclosure will be required from the successful applicant. Convictions or other disclosures will not necessarily be a bar to obtaining a position with this Authority.

FOR COMPLETION BY THE APPOINTING OFFICER

I confirm that I have discussed the above disclosures with the applicant.

Signed:	Position held:	Date:

16. References

•	Please give details of two referees whom we may ask about your suitability for the job. 

•	You are requested to give referee details from two employers, the first of which must be your current or most recent employer. 
•	If you are unable to provide two employment references, please speak to the Shropshire Recruitment Team and they will provide further guidance. 
•	You should not name a relative as a referee. 
•	References will usually only be taken up if you are selected for interview. 
•	We will not confirm an offer of appointment until we have received a satisfactory reference from your present or most recent employer (or school if you are a school leaver). 

(1) Name:	(2) Name:	
Address:	Address:	

Postcode:	Postcode:

Telephone number:	Telephone number:

Email address:	Email address:

Occupation:	Occupation:

Working relationship to candidate:	Working relationship to candidate:

May we contact these referees without asking you?  (1)	(2)

17. Your Signature

I certify that to the best of my knowledge the details provided on this form and all other supporting papers are true and correct. Furthermore, I understand that if I have provided false or misleading information in response to any questions on this form or have failed to disclose information, this will result in the termination of any contract of employment entered into, or the withdrawal of any offer of employment. I also hereby give my explicit consent to the processing of data contained or referred to on this form, in accordance with the Data Protection Act 1998 and any subsequent legislation.

Signature of Applicant:	Date:

N.B. If you application is submitted electronically you will be asked to sign this form if invited to interview.

Equal Opportunities and Recruitment

Equal Opportunities Policy

*Our vision is to improve significantly the quality of life for Shropshire people by working together, which is at the heart of everything we do. Shropshire Council is committed to this vision.

*We will strive for the highest possible public service and professional standards, and will be accountable to Shropshire people for everything we do.

*We believe that equal opportunity is about treating people fairly, openly and honestly and recognising that people all have different needs, cultures, experiences and expectations.

*It is the policy of Shropshire Council to ensure that no person, whether a job applicant, employee, service user or third party receives any less favourable treatment because of his or her gender, marital status, family status, lifestyle, age, ethnicity, religion, sexual orientation, disability, political affiliation, trade union membership or any other condition or requirement which cannot be shown to be justifiable.

We take positive steps to promote Equality & Diversity in employment such as our Lesbian, Gay & Bisexual network and the Employees Disability Network.

Equality Act 2010

The Equality Act 2010 places a general duty on the Council to promote equality. This means that in everything we do, we need to:

*Eliminate unlawful discrimination, harassment and victimisation.

*Advance equality of opportunity.

*Foster good relations between different people.

Policy Statement for Applicants with Disabilities

Under the Disability Discrimination Act 1995, employers have a duty to make reasonable adjustments where, compared to a non-disabled person, a disabled person is substantially disadvantaged by either the working arrangements (which include the recruitment process) or the working environment.

The Act defines a disabled person in the following way:

"A disabled person is anyone who has or has had a physical or mental impairment which has a substantial and long term effect on their ability to carry out normal day to day activities."

You should be aware that we may ask you to give details of your disability should you be invited to interview. Any supporting information, for example a letter from a Disability Employment Adviser, would be helpful. The information you provide will be shared with the appointing officer responsible for shortlisting applicants and organising the selection process. You should be aware that you may be asked to give details and any supporting information.

We have made a commitment to improve employment opportunities for people with disabilities, and have adopted the Employment Department’s two ticks symbol ‘Positive About Disabled People’. This means that the Council has undertaken to guarantee an interview to all applicants with a disability who meet the essential requirements of the job as contained in the person specification.

Please complete the recruitment monitoring form on the next page.

Recruitment monitoring form

Monitoring form number

This sheet will be detached from your application form and will not be seen by anyone involved in the selection process. We will use this information for monitoring our recruitment processes and, if you are appointed, for our personnel/payroll records.

Surname:	First name:	
Known as:	Second name:	
Previous other names:	Preferred title:	
Date of Birth:	Age:	
Place of Birth:		
Post applied for:	Directorate/School:	
			
Gender:	Job share:		
	
Ethnic Origin: I would describe my ethnic origin as…	
White: --	Please Select --		
Black or Black British: -- Please Select --	
Asian or British Asian: -- Please Select --	
Mixed: --	Please Select --		
Chinese or other ethnic group: --	Please Select --	

Religion: In terms of my religion, I would describe myself as:

Of other religion:

Sexual Orientation:

Disability: For definition, please refer to our policy statement overleaf.

In line with this policy, do you consider yourself to have a disability?

If you are selected for interview are there any special arrangements we would need to make

for you?

(If YES, and you are successful in obtaining an interview, we will contact you after the

shortlist has been drawn up to discuss arrangements).

Advert: Where did you see this vacancy advertised? Please specify.

Local Newspaper	National Newspaper	
Job Centre	Professional Journal	
Shropshire Council website	Internet	
Other