Title Mr Mrs Miss Ms Dr Surname Given Name Date Of Birth Email Phone Address & Postcode Home Tel NI Number Qualifications Training and development Previous employment References 1 References 2 Do you have your own car or motorbike Yes No Emergency Contact Name & Number Bank Account Details Account Name Account Number Sort Code DBS Upload Right to work (Biometric Card / share code) Proof of Address Passport Page Passport Photograph CV Upload NI Letter Upload UK Driving Licence Additional Documents Additional Documents Training Certificate Upload Vaccination Proof Upload Employment History Name & address of employer Date from: Date till: Position Held Key Responsibilities Reason for Leaving Reason gaps in your employment Name & address of employer Date From: Date Till: Position Held Key Responsibilities Reason for Leaving Gap in employment Name and address of employer Date from: Date till: Position Held Key Responsibilities Reason for Leaving Reason gaps in your employment EXPERIENCE OF WORKING IN THE FOLLOWING AREAS? Older people People with Dementia People with Parkinson’s Care after a stroke Rehabilitation Palliative care Multiple Sclerosis Motor Neurone Children People with learning disabilities People with mental health People with physical disabilities TRAVEL Car Public Transport Walking Monday Monday Tick To Confirm 6am till 3pm 3pm till 12am Not Available Tuesday Tuesday Tick To Confirm 6am Till 3pm 3pm Till 12am Not Available Wednesday Wednesday Tick To Confirm 6am Till 3pm 3pm Till 12am Not Available Thursday Thursday Tick To Confirm 6am Till 3pm 3pm Till 12am Not Available Friday Friday Tick To Confirm 6am Till 3pm 3pm Till 12am Not Available Saturday Saturday Tick To Confirm 6am Till 3pm 3pm Till 12am Not Available Sunday Sunday Tick To Confirm 6am Till 3pm 3pm Till 12am Not Available (DDA 1995) DISABILTY DISCRIMINATION ACT 1995 (DDA) If you have a disability as defined in the DDA (Disability Discrimination Act 1995), please give details below. It will only be used in the interview process to assess whether any adjustment would be needed for you to carry out the work of the post. Please also use the space below to let us know any special requirements you have to enable you to attend at interview, if short-listed Confirm DISABILTY DISCRIMINATION ACT 1995 (DDA) Yes No CRIMINAL RECORD DECLARATION FORM (exempt positions) This form must be completed by all applicants. The information disclosed on this form willnot be kept with your application form during the application process. Policy statement on recruiting applicants with criminal records This post is exempt from the Rehabilitation of Offenders Act 1974 and therefore applicants are required to declare any convictions, cautions, reprimands and final warnings that are not protected (i.e. that are not filtered out) as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) order 1975 (as amended in 2013). For further information on filtering please refer to Nacro guidance and the DBS website. We recognise the contribution that ex-offenders can make as employees and volunteers and welcome applications from them. A person’s criminal record will not, in itself, debar that person from being appointed to this post. Any information given will be treated in the strictest confidence. Suitable applicants will not be refused posts because of offences which are not relevant to, and do not place them at or make them a risk in, the role for which they are applying. All cases will be examined on an individual basis and will take the following into consideration: Whether the conviction is relevant to the position applied for • The seriousness of any offence revealed • The age of the applicant at the time of the offences(s) • The length of time since the offence(s) occurred • Whether the applicant has a pattern of offending behaviour • The circumstances surrounding the offence(s), and the explanation(s) offered by the person concerned • Whether the applicant’s circumstances have changed since the offending behaviour. It is important that applicants understand that failure to disclose all convictions, cautions, reprimands or final warnings that are not protected could result in disciplinary proceedings or dismissal. Further advice and guidance on disclosing a criminal record can be obtained from Nacro. Any Convictions Do you have any convictions, cautions, reprimands or final warnings which are not protected as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) order 1975 (as amended in 2013)? Please confirm any convictions Yes No If you have answered yes, you now have two options on how to disclose your criminal record Option 1: Please provide details of your criminal record in the space below. Option 2: You can disclose your record under upload a word document EQUAL OPPORTUNITIES FORM This sheet does not form part of the selection process. It will be retained by Human Resources purely for monitoring purposes. Avant strategies recognise and actively promotes the benefits of a diverse workforce and is committed to treating all employees with dignity and respect regardless of race, gender, disability, age, sexual orientation, religion or belief. We therefore welcome applications from all sections of the community Race Relations (Amendment) Act 2000 Asian or Asian British Bangladeshi Indian Pakistani Any other Asian background Mixed White & Asian White & Black African White & Black Caribbean Any other mixed background Other Ethnic Group Chinese Any other ethnic group Black or Black British African Caribbean Any other Black background White British Irish Any other white background Undisclosed I do not wish to disclose Employment Equality Regulations 2003 Please select the option which best describes your sexuality Lesbian/Gay woman Gay man Bisexual Heterosexual I do not which to disclose my sexual orientation Please indicate your religious belief Atheism Buddhism Christianity Islam Jainism Sikhism Judaism Hinduism other I do not wish to disclose to religion/belief Date Signed: Location Tameside Stockport Rotherham Rochdale Leicester Gloucester Send
