Application Form
Student Progression Ambassador
Position(s) to be
considered for:
Sutton Scholars Mentors
Realising Opportunities Mentor
Pathways to Law Mentor
If completing by hand, then this application should be typed, or you should ensure that you write clearly in black pen, so that this application is easy to
read when photocopied. Should you require assistance in completing this application form, then please contact outreach@warwick.ac.uk
1.
Personal Details
Last Name / Family Name:
First Name(s):
Title:
Term
Time
Address:
Telephone Numbers:
Post Code
Daytime
Evening
Mobile
E-Mail Address:
Home
Address:
Post Code
Telephone Number:
2.
Daytime
Evening
Student ID number, Course &
Year:
National
Insurance
Number:
Are you in your final year of
study? Yes No
Do you have use of a car at
University?
Yes / No
Did your parents / carers go to
university?
Yes / No
Did you attend a state school?
Yes / No
Previous experience of working with young people.
Have you previously been involved or participated in any activities involving young people (even as a secondary
school / college student)? e.g. mentoring, school or college visits to universities, subject specific conferences etc.
Especially working with young people from a disadvantaged background.
Yes / No
If yes, please specify
3.
Previous Employment / Training
Please provide details of any paid / unpaid / voluntary work or training that is relevant to this post
(Do not overrun the page boundary; continue on a separate sheet if necessary)
Employer’s Name:
Dates
From
4.
Post Title:
Main Responsibilities:
To
General & Further Education
Include details of your current studies and previous qualifications.
(Do not overrun the page boundary; continue on a separate sheet if necessary)
School / College / University / Professional Body:
Qualifications in progress / obtained:
Grade /
Level:
Date
Obtained:
5.
References
Please give the names of people who could provide a reference regarding your suitability for the post for which you are applying.
One of these should be your present or most recent employer. School / College leavers should give the names of lecturers /
tutors / headteachers. You should not give friends or relatives as referees.
Name
N/A
Job Title / Position
N/A
Address
N/A
Post Code
N/A
Telephone Number
N/A
E-Mail Address
N/A
May we request a
reference prior to
interview?
6.
Yes
Yes
Yes
No
No
No
Supporting Information
Please provide supporting information, outlining any experience, skills and knowledge relevant to the post for which you are
applying. Include any key strengths, interests or previous experience that will support your application. Please refer to the job
descriptions.
Please note that for the individual mentoring programmes you will need to mention specific skills and/ or knowledge relevant to
each post that you are applying for. For example if are you applying for the Pathways to Law, then you will need to demonstrate a
good working knowledge around the subject of Law.
Any additional pages should be firmly attached to this form, marked clearly with your name.
Criminal Convictions and Cautions
If you have any unspent criminal convictions, or have any criminal proceedings pending against you, then please give full details
as a separate document, clearly stating your name, and the post title of the post for which you are applying. This document
should be either enclosed in an envelope, marked ‘Private and Confidential’, and sent with your application form, detailing your
name and the post title, or e-mailed to outreach@warwick.ac.uk with ‘Criminal Conviction Information’ detailed in the subject
box. This information will only be opened if your application is shortlisted. If you are unsuccessful at this stage, then this envelope
will be destroyed unopened, or this e-mail will be deleted unread.
N.B. Spent convictions will still have to be declared on applications for certain occupations, such as those involving work with
children or vulnerable groups, e.g. the University Nursery, Nursing or Medical Practitioner posts, and Chartered or Certified
Accountancy posts.
Data Protection Act 1998
The information that you provide is subject to the protection of the Data Protection Act 1998, and will not be used for any
alternative purpose without your consent.
Declaration
To the best of my knowledge and belief, the information contained in this form is accurate. I understand that giving false
information, or failure to supply details, will invalidate an offer of employment, or lead to termination of employment.
Please note that, in submitting this application, you have accepted these terms, and agree to this declaration.
WHERE REQUIRED, EVIDENCE OF QUALIFICATIONS WILL BE NECESSARY PRIOR TO COMMENCEMENT OF
EMPLOYMENT.
Signed: (type your name
if e-mailing this form)
Date:
Acknowledgement of This Application
Please send this fully completed application form, and any supporting information, by post to: Outreach Team, Student
Admissions and Recruitment Office, University House, The University of Warwick, Coventry CV4 8UW, United Kingdom or
electronically to outreach@warwick.ac.uk. An email to acknowledge receipt of your application will be sent to the email address
you provided on this form.
Recruitment and Staff Monitoring Form
Post Title:
Student Progression Ambassador/ Sutton
Scholars Mentor/ Pathways to Law Mentor
/ Realising Opportunities Mentor
Please refer to the vacancy advertisement
The university is committed to ensuring that applicants are selected for appointment on the basis of their abilities relevant to the job.
Completion of this form will help us to ensure that our policy and procedures are effective in avoiding discrimination, and in promoting equal
opportunities in recruitment. The information that you provide will be used for monitoring and for statistical data purposes, and will form the basis of the
personnel record for the successful candidate. This information will not be seen by those involved in the shortlisting process.
Please help us, by completing the following questions:
Last Name / Family Name:
First Name(s):
Department:
Date of Birth:
Age:
Country of Current
Nationality:
Gender:
Do you require a Work Permit to work
in the United Kingdom?
Yes
No
Male
Female
I would describe my ethnic origin as:
White:
British
Irish
Any Other White Background, please specify
Black or Black British:
Caribbean
African
Any Other Black Background, please specify
Asian or Asian British:
Indian
Pakistani
Bangladeshi
Any Other Asian Background, please specify
Mixed:
White and Black Caribbean
White and Black African
White and Asian
Any Other Mixed Background, please specify
Chinese or Other:
Chinese
Any Other Background, please specify
Have you ever been convicted of a criminal offence?
Yes
No
Are there any criminal proceedings pending against you?
Yes
No
(You do not need to disclose convictions deemed as spent under the
Rehabilitation of Offenders Act 1974.)
If you have ever been convicted of a criminal offence, or there are any
criminal proceedings pending against you, then please refer to the section
labelled Criminal Convictions and Cautions on the Application Form.
Do you consider yourself to have a disability?
Yes
No
If you consider yourself to have a disability, then please state
the type of disability that affects, or has affected, your ability to
carry out any aspect of your job.
If you consider yourself to have a disability, then, based upon
your past experience, what equipment or reasonable
adjustments do you require to help you carry out your work?
Do you have any childcare / dependants responsibilities?
Yes
No
(This information is used purely for monitoring our family-friendly policies.)
Where did you see this vacancy advertised?
All student email
Careers Email
Department
Flyer
SU (inc plasma screen)
Website
Are you currently employed by the University of Warwick or
UniTemps?
Yes
No
If Yes, then please specify your University
Number or your UniTemps number