Notes (a) Under the Criminal Justice & Courts Services Act 2000 it is an offence for an individual who has been disqualified from working with children to knowingly apply for, offer to do, accept, or do any work in a ‘regulated position’. The position you are applying for is a “regulated position”. (b) Canvassing, directly or indirectly, an employee or governor will disqualify the application. (c) Candidates recommended for appointment will be required to provide a satisfactory Enhanced DBS certificate and complete a pre-employment medical questionnaire and may be required to undergo a medical examination. (d) This organisation is under a duty to protect the public funds it administers, and to this end may use the information you may provide as part of the recruitment process for the prevention and detection of fraud. It may also share this information with statutory bodies responsible for auditing or administering public funds for these purposes. Declaration I certify that, to the best of my knowledge and belief, all particulars included in my application are correct. I understand and accept that providing false information will result in my application being rejected or withdrawal of any offer of employment, or summary dismissal if I am in post, and possible referral to the police. I understand and accept that the information I have provided may be used in accordance with paragraph 13 above, and in particular that checks may be carried out to verify the contents of my application form. Signature of Applicant: Print Name: Date:
Part 3: Equality and Diversity Monitoring This section will be separated from part 1 and part 2. Collection of equality information is solely for monitoring purposes to ensure that our policies and procedures are effective. We also collect this data in accordance with the general and specific public sector equality duties under the Equality Act 2010. Any data you enter onto this monitoring form will only be used for monitoring purposes and will not be used in assessing and or scoring your application or during the interview process. This information is kept fully confidential and access is strictly limited in accordance with the Data Protection Act. Ethnicity Workforce census code Please tick White WBRI British English Welsh Northern Irish Scottish WIRI Irish WIRT Traveller of Irish Heritage WROM Gypsy / Roma WOTH Any other White background Mixed MWBC White and Black Caribbean MWBA White and Black African MWAS White and Asian MOTH Any other Mixed background Asian or Asian British AIND Indian APKN Pakistani ABAN Bangladeshi CHNE Chinese AOTH Any other Asian background Black or Black British BCRB Black – Caribbean BAFR Black – African BOTH Any other Black background Other ethnic group ARAB Arab CHNE Chinese REFU Refused/Prefer Not to Say OOTH Any other ethnic group Sexual orientation Please tick Bi-sexual Gay Man Gay Woman Heterosexual Other Prefer not to say Gender Please tick Female Male Transgender Prefer not to say Personal relationship Please tick Single Living together Married Civil Partnership Prefer not to say Religion or belief Please tick No religion Christian (including Church of England, Catholic, Protestant and all other Christian denominations) Buddhist Hindu Jewish Muslim Sikh Any other religion (Write in) Prefer not to say Disability Do you consider that you have a disability? Please tick Yes - Please complete the grid below No Prefer not to say My disability is: Physical Impairment Sensory Impairment Mental Health Condition Learning Disability/ Difficulty Long standing illness Other Prefer not to say