MYSTERY SHOPPER APPLICATION FORM
PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS
Title
First Name(s)
Last Name
Any Other names you have been
known by
Permanent Home Address
Previous address
Postcode:
Postcode:
Number of years at this address:
Number of years at this address:
(If less than five years please complete the box
on the right.)
Date of Birth and Age
Place of Birth
D.O.B:
Age:
National Insurance Number
Nationality
Home Telephone Number
Work Telephone Number
Mobile Telephone number
E Mail Address
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Mystery Shoppers need to be impartial and independent. To enable us to
identify any possible conflicts of interest please complete the section
below.
Are you :
a police officer or special constable?
YES/NO
a member of police staff?
YES/NO
a volunteer for Northamptonshire Police
YES/NO
a member of staff of the Northamptonshire Office of
the Police and Crime Commissioner, or their immediate family?
YES/NO
If you have answered yes to any of the above please provide further
details
Please provide us with details of any part-time or full-time work over the
last 5 years (most recent first)
Name and address of
employer
Dates
Position held and
duties
Names and address of
employer
Dates
Position held and
duties
2
Do you do any other voluntary work or public service?
YES/NO
If YES please give details below.
Why do you want to be a Mystery Shopper?
Do you have a current full current car or motorcycle license?
This will not affect your application but may influence which tasks
you are set, if successful.
YES/NO
3
Please tell us what skills, experience and qualities you have that would
make you a good Mystery Shopper. You may want to include your
experience of good communications skills or any voluntary duties or
public service you are involved in.
Skills
Experience
Qualities
(please continue on a separate sheet if necessary)
Do you consider yourself to be disabled?
YES/NO
Do you have any medical condition that may affect your ability to
carry out the duties of a Mystery Shopper?
YES/NO
Are there any special arrangements you would require if attending
an interview? (eg. access, disabled parking)
YES/NO
4
If you have answered YES to either of the above questions please
provide more details below. (this will not necessary affect your
application)
**The Police and Crime Commissioner is an equal opportunity employer and actively
encourages applications from people with disabilities. Applicants with disabilities who
demonstrate that they meet the essential criteria in the Person Specification will be
guaranteed an interview. The Disability Discrimination Act 1995 defines a disabled
person as someone who has “a physical or mental impairment which has a substantial
and adverse long-term effect on his or her ability to carry out normal day-to-day
activities.”**
CRIMINAL CONVICTIONS
In the last five years have you had any criminal convictions or been convicted
of any offence punishable by imprisonment?
YES/NO - If yes please provide more details below.
The inclusion of this question and the provision of the information is a
requirement in all applications but may not necessarily affect your application.
Offences covered by the Rehabilitation of Offenders Act 1974 need not be
declared above if spent.
To help us with recruitment in the future please advise how/where you
learnt that we were looking for Mystery Shoppers?
REFERENCES – Please give the name of two referees who have agreed
to support your application. One should be a professional e.g.
teacher/solicitor accountant/community leader.
The other can be a character reference who should have known you for
at least 2 years (and should not be a family member)
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Referee 1
Name
Address
Referee 2
Name
Address
Telephone
No.
Position
Telephone
No.
Position
DECLARATION
I agree to the Police and Crime Commissioner undertaking a Police National
Computer (PNC) and Force Intelligence System (FIS) check in connection
with my application as a volunteer. I have read the information supplied to me
concerning the duties and responsibilities of a Mystery Shopper and would be
prepared, if my application is accepted, to complete the appropriate
undertaking in respect of confidentiality.
Signed:
Date:
WHAT TO DO NOW
The completed application form should be sent to
Alexa Daly
Northamptonshire Police and Crime Commission
The West Wing
Police Headquarters
Wootton Hall
Mereway
Northampton, NN4 0JQ
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