Job Application Form
(For jobs requiring a CRB check)
Please read the enclosed Guidance Notes carefully before completing this form.
About the job you are applying for:
Job Title:
Location:
Job Reference No:
Closing date:
Where did you see the job advertised or hear about it?
(Please put one answer only – stating the title of the newspaper or website)
Section 1
Title:
First name(s):
Last name:
Preferred name:
Date of birth*:
Gender*:
Age*:
Male
Female
Address:
Postcode:
Contact Telephone No:
Email Address:
(preferred communication method)
N.I. Number:
Marital Status*:
(please tick)
Single
Married
Civil Partnership
Prefer not to disclose
Flexible Working
Are you applying to do this job on a job share basis? Yes
No
If possible
If Yes, please give details of the number of hours/days per week that you wish to apply for:
.
If you wish your application to be considered on a joint basis with someone else also wishing
to job share, please give his/her name:
*For statistical purposes only – not
used as part of the selection process
Page 1 of 9
Leading Lives requires all the following questions to be completed by all applicants.
However, the questions regarding religion and belief and sexual orientation are to be
completed on a voluntary basis.
Ethnic Origin*
Please select one description from numbers 1–18 (below) that best fits your ethnic origin. If
you
feel the choices do not provide a suitable option, please write how you would describe your
ethnic origin in the space provided.
8. Indian
1. British
15. Chinese
9. Pakistani
2. Irish
10. Bangladeshi
3. Any other White origin
11. Any other Asian origin
16. Gypsy / Traveller
17. Other – please specify:
4. White & Black Caribbean
5. White & Black African
12. Caribbean
6. White & Asian
13. African
7. Any other mixed origin
14. Any other Black origin
18. Prefer not to disclose
Your Ethnic Origin Description 1-18
Nationality*
Please tell us your nationality
e.g. British Citizen, Portuguese Citizen
Prefer not to disclose
Religion or Belief*
Please see guidance notes for more information on why we are asking for this information.
Please select from the following list:
Buddhist
Bahá’í
Hindu
Muslim
Jewish
Rastafarian
Zoroastrian
No religion/belief
*For statistical purposes only – not
used as part of the selection process
Christian
Jain
Sikh
Pagan
Prefer not to disclose
Other (please specify):
Humanist
Page 2 of 9
Sexual Orientation*
Please see guidance notes for more information on why we are asking for this information.
Please select from the following list:
Heterosexual
Gay
Bisexual
Lesbian
Prefer not to disclose
Disability*
The Equality Act 2010 defines a person as having a disability if he/she has a
physical or mental impairment which has a substantial and long term adverse effect on his/her
ability to carry out normal day to day activities.
Do you have a disability as defined above?
Yes
No
If you have a disability, are there any arrangements which we can make for you if you are
called for an interview and/or work based exercise? Yes
No
If Yes, please specify, (e.g. ground floor venue, sign language interpreter, audio tape etc.)
We offer a guaranteed interview to all disabled candidates who meet the minimum
criteria for a job vacancy.
*For statistical purposes only – not
used as part of the selection process
Page 3 of 9
Section 2
Job Reference No:
Your Initials:
How you meet the Selection Criteria
Please use this section to provide evidence of how you meet the criteria set out in the job
advert. Tell us about things that you have been responsible for and achievements you
have made, giving clear examples. Examples could come from paid or unpaid work or
any other activities you have undertaken that you feel are relevant to the job you are
applying for.
You should also use this section to include other information about why you want the job
and anything else you wish to say.
If there is not enough space on this form If there is not enough space on this form please
continue writing in a separate word document and attach it to your email along with this
form (clearly marking your Name, National Insurance and the reference number for the
job you are applying for).
*For statistical purposes only – not
used as part of the selection process
Page 4 of 9
Section 2 continued
*For statistical purposes only – not
used as part of the selection process
Page 5 of 9
Section 3
Work and Other Relevant Experience
Please list below a complete record of your employment and other relevant activities,
either paid or unpaid (e.g. voluntary work etc.). Please start with your current or most
recent position and work backwards, ensuring that any gaps are explained.
Date
(mm/yyyy)
Name and
Nature of
Business
Job Title and brief
description of duties and
responsibilities
Reason for
leaving
From
To
From
To
From
To
From
To
From
To
From
To
From
To
Please continue on a separate sheet if necessary (clearly marking your National
Insurance number and the reference number for the job you are applying for on each
separate sheet).
*For statistical purposes only – not
used as part of the selection process
Page 6 of 9
Section 4
Qualifications and Training
Secondary Education (CSE, GCE, GCSE, RSA, A LEVEL, etc., or other equivalent)
Date (mm/yyyy)
Examination
Type
Subject(s)
Grade Achieved
Further & Higher Education (Degree, Diploma, BTEC, NVQ, etc., or other equivalent)
Date (mm/yyyy)
Qualification
Subject
Pass level or
grade
Other relevant qualifications or training including membership of professional
bodies and Driving Licence.
Please be aware that proof of qualifications identified as essential to the role, including
driving licence will also be required at interview – however do not send these now,
further information will be sent to you should you be invited to interview.
*For statistical purposes only – not
used as part of the selection process
Page 7 of 9
Section 5 – Declarations
Entitlement to Work in the UK
Are you currently eligible to work in the UK?
Yes
No
(please tick one box)
If Yes, and there are conditions attached, for example start and finish dates, please
specify the details here:
No, what type of work permit do you require?
To comply with The Immigration, Asylum & Nationality Act 2006 and additional
amendments, all
prospective employees will be asked to supply evidence of eligibility to work in the UK.
We will ask to see and take a copy of an appropriate official document as set out in the
Home Office guidelines – however do not send these now, further information will be
sent to you should you be invited to interview.
Canvassing of Board Members or Senior Employees
Canvassing of Board Members or Senior Employees by you or on your behalf is strictly
forbidden and may invalidate your application. Please indicate here if you are related to
any Board Member or Senior Employee of Leading Lives, giving their name and job title,
if known. Please state None if appropriate.
Criminal Convictions
The job you are applying for has been identified as involving supervising, caring for or
otherwise connected with children, young people or vulnerable adults. In view of this,
you must declare all convictions, cautions and/or bindovers for criminal offences,
even where they are
“spent” as defined by the Rehabilitation of Offenders Act 1974 and subsequent
regulations. You are also required to give details of any reprimands or warnings that you
may have received. A Criminal Records Bureau (CRB) check will also be required.
Details of criminal convictions, cautions and/or bindovers, reprimands or
warnings:
Please state None if appropriate and continue on a separate sheet if necessary, clearly
marking your candidate reference number and the reference number for the job you are
applying for on each separate sheet:
*For statistical purposes only – not
used as part of the selection process
Page 8 of 9
References
Please give the names and addresses of two people who have known you for at least 5
years (where possible) and would be willing to supply a reference about you. At least
one reference should be your current/most recent employer (teacher or tutor for school
leavers).
Name:
Name:
Address:
Address:
Postcode:
Postcode:
Email:
Email:
Tel No:
Tel No:
Employer
Educational
Personal
Employer
Educational
Personal
Organisation (if applicable):
Organisation (if applicable):
Normally references will be requested for candidates invited to interview.
May we contact the people you have specified above if you are invited for
interview?
Yes
No
Yes
No
(If No, we will contact you for your permission before requesting references)
Leading Lives operates a policy of open references.This means that you may read any
references received in relation to you, on written request.
Declaration and Data Protection Statement
• I consent to Leading Lives carrying out checks and using information provided from the checks
and this application form when making a decision about my suitability to work with or be in
regular contact with children/vulnerable adults
• I understand that Leading Lives will share any information they obtain about me with other
organisations where the law requires them to, including where information raises concerns of an
adult/child protection nature.
• I understand that it is an offence to make a statement which is false or misleading in an
application for registration.
• I give consent for Leading Lives to carry out checks and use the information from the
declaration and consent form and third party information prescribed in regulations made under
the Safeguarding Vulnerable Groups Act 2006, to make a decision about my suitability.
• I consent to Leading Lives registering an interest with the Independent Safeguarding Authority
(ISA) through my unique ISA reference number.
• To the best of my knowledge, the information I have supplied on this form is correct.
I understand that giving false information or omitting relevant information could disqualify my
application and, if I am appointed, could lead to an offer being withdrawn or my dismissal. I
consent to the information I have provided being verified, which I understand will involve
providing relevant documentation for checking and contacting referees/previous employers.
Signed:
Date:
In completing and returning this application you are consenting to the processing of
data therein and that this will comply with the Data Protection Act 1998.
Details of your application including your personal details will be stored in our archives and database
for up to 12 months following successful completion of this recruitment process.
Please also be aware that the outcome of this application including your name and National
Insurance number may be shared with JobCentre Plus (a section of the Department for Work
and Pensions) for statistical monitoring purposes only
*For statistical purposes only – not
used as part of the selection process
Page 9 of 9