Name & Address of Employer	Position Held	Dates of Employment	Reason for Leaving

Date From	Date To	Reason

Body	Dates	Qualification

What work or life experience, skills or personal interests do you have that would help you to do this job? Please use this space to provide us with any further information which you feel would help us to consider your application. (Please refer to the job description and person specification).

Referees must not be members of your own family. The first reference must be your present or last employer. If you do not have a present or previous employer please give the names of two people who can provide evidence of your character, experience and skills.

Reference #1

Reference #2

Declaring Offences:
The work for which you are applying involves substantial opportunity for access to vulnerable adults. It is therefore exempt from the Rehabilitation of Offenders Act 1974. you are therefore required to declare any convictions you may have, even if they would be regarded as “spent” under this Act, or any pending prosecutions, cautions or bind overs. The information you give will be treated in confidence and will only be taken into account in relation to an application where the exemption applies. The disclosure of a criminal record, or other information, will not debar you from appointment unless the selection panel considers that the conviction makes you unsuitable for appointment. In making this decision, we will consider the nature of the offence, how long ago it took place, and what age you were when it was committed and any other factors which may be relevant, including appropriate considerations in relation to our Equal Opportunities Policy. Failure to declare a conviction, caution or bind over may, however, disqualify you from appointment, or result in summary dismissal if the discrepancy comes to light.

Disclosure Information:
Do you have any convictions, cautions, reprimands or final warnings that are not “protected” as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013).

Health Declaration:
If you are selected for shortlisting you may be required to complete a declaration of health form and bring it with you to the interview. Failure to disclose a condition that may effect your employment could disqualify you from appointment.