Title: Official Use Only
Author: Kelly Donnarumma
Last saved by: Ann Stephens
Company: Southampton City Council

Official Use Only | | APPLICATION FORM Private and Confidential | |
No | | | |
SL Yes / No | | | |
NSL Reason | | | |
Post applied for: | |
Post title: Wrap Around Care Assistant School Name: Fairisle Infant and Nursery School | | Please return this form back to the school where you are applying.  Contact details for the school can be found on the vacancy advert.
This form should be completed in full.  You should not send a C.V. (curriculum vitae) as an alternative to completing any section of this form.  However you may use additional sheets of paper if there is not enough space to enter relevant information on any section.  Please complete the form clearly in black ink or typescript.

Your application will be judged solely on the information provided in accordance with the person specification.

PERSONAL DETAILS

Surname: | | Title (Ms, Miss, Mrs, Mr etc. : |
Forenames: |
Home Address: |
| Post Code : |
N.I. Number : | |
Telephone Number(s) (to include STD codes) |
Home 🕿: |
E-mail 🖳: |
Mobile 🕿: |
Work🕿: |
May we contact you at work? | Yes | ☐ | No | ☐
Please note we will exercise the utmost discretion should you authorise us to contact you at work.
EDUCATION, TRAINING AND NON-VOCATIONAL EXPERIENCE

Please give relevant information about education received, and qualifications obtained with dates. 

Secondary Schools, Colleges and Universities attended

Dates

Qualifications gained or pending (please state subject, 
level and date obtained)

Grade

| From | To | |
N.B. You will be asked to produce the certificates where your qualifications are a requirement of the job
Do you have any non-vocational experience/skills which may be relevant to your application?
e.g. family duties, voluntary work, leisure interests | Yes | ☐ | | No | ☐ |
If yes, please state
Do you have any language skills? | Yes | ☐ | | No | ☐ |
If yes, please state languages and level of skill (including sign language interpretation) |

MEMBERSHIP OF PROFESSIONAL BODIES

Body

Grade of 
Membership

By Examination
Yes/No

Date

ATTENDANCE AT TRAINING COURSES

Course | Duration | Date

PRESENT EMPLOYMENT (if applicable)

Employer |
Job Title |
Date appointed |
Notice period required |
Current wage/salary and grade (if applicable) |
Please also list any other jobs you currently have (paid or unpaid) |
Reason for wishing to leave present employment |

EMPLOYMENT HISTORY
Previous paid employment (if applicable).  List all other employers (most recent first) using a separate sheet if necessary.  Account for any gaps in employment (subject to provisions 
relating to disclosure under the Rehabilitation of Offenders Act 1974).
Employer’s Name, Address and type of business | Post held | Dates
| | From | To
| | DD | MM | YY | DD | MM | YY

Have you previously worked for Southampton City Council? | Yes | ☐ | No | ☐ |
Please provide details of your most recent appointment:
Dates (From/To): |
Position: |
Location (Directorate and Division): |

OTHER RELEVANT INFORMATION

Other relevant information and experience including current duties.  The information you provide 
in this section will be used in assessing your application.  Please use this space to state your reasons for applying for the post relating your skills, experience and personal qualities to the person specification and requirements of the job.  If you are a disabled person, but are unable to meet some of the job requirements because of your disability, please document this in this section.
Please continue on a separate sheet if necessary.

MISCELLANEOUS
Are you the parent, grandparent, partner, child, stepchild, adopted child, grandchild, brother, sister, aunt, uncle, nephew or niece of an existing Councillor or employee of the Council. | Yes | ☐ | No | ☐
If Yes, please give:  Name: | | Place of Work: |
Do you have a business or potential business relationship with the person named above? | Yes | ☐ | No | ☐
N.B. All forms of canvassing will automatically disqualify candidates from appointment e.g. you must not ask a Councillor or Officer of the Council to use their influence to help you gain this job.
Are you currently an elected member of a Local Authority? | | Yes | ☐ | No | ☐
Have you been nominated for a forthcoming Local Election? | | Yes | ☐ | No | ☐

Driving Licence
Only complete below, if according to the person specification, driving is a requirement of the job:
Do you have a full current driving licence? | | Yes | ☐ | No | ☐
If yes, please indicate which class of vehicle this covers (please use the letters detailed on your licence)

Job Share (see guidance notes)
Do you wish to apply for this post on a job share basis ? | | Yes | ☐ | No | ☐
If yes, I would prefer to work/I can only work: | Days | | Hours |
If there are no other applicants wishing to job share would you be willing to consider the post on a full time basis?
| Yes | ☐ | No | ☐

REFERENCES

Give the name and address of two referees of whom confidential enquiries may be made regarding your suitability for the post.  One should be your present or last employer, the other preferably a previous employer or someone who has known you in a professional capacity.  If you are a School, College or University leaver, your Headteacher or Tutor.  PLEASE PRINT DETAILS

Name | | Name |
Post title | | Post title |
Organisation | | Organisation |
Address | | Address |
Post Code | | Post Code |
Telephone (incl. STD code) | | Telephone (incl. STD code) |
E-mail | | E-mail |
Fax No. | | Fax No. |
Capacity in which known to you | | Capacity in which known to you |
It is normal for us to contact both referees after shortlisting.  May we contact your referees at this stage?
| Yes | ☐ | No | ☐ | | Yes | ☐ | No | ☐

Rehabilitation of Offenders Act

You have been asked to provide details about previous convictions for criminal offences.  You should read the attached guidance notes before doing so.

It is essential that you complete and return the attached Rehabilitation of Offenders Act Form.

DECLARATION

I confirm to the best of my knowledge that the information given in this form is accurate and that I have not omitted any facts which may have a bearing on my application for employment.  (WARNING: Any person appointed to the Authority having given false information will be liable to summary dismissal)
Signed | | Date |
PLEASE GIVE ANY DATES ON WHICH YOU WOULD NOT BE AVAILABLE FOR INTERVIEW:

I understand that if I am appointed, personal information about me will be computerised for personnel / employee administration purposes in accordance with the General Data Protection Regulations. This may include analysis for management purposes and statutory returns.

Where applicable, I will be subject to the regulations on political restrictions as defined in Local Government and Housing Act 1989.

I understand that, should any of the particulars I provide in this application be found to be false within my knowledge, or should there be any omission of material fact, this may be reported to the police as well as leading to my application being rejected or the contract being null and void if I have already been appointed.

More detailed information about the School’s handling of your personal data can be found in its privacy notice available on the school website or available on request.  Additionally, Southampton City Council’s Privacy Policy can be found on line at (http://www.southampton.gov.uk/privacy

EQUALITY OF OPPORTUNITY
GUIDANCE NOTES

Southampton City Council is an Equal Opportunities Employer.  Its aim is to ensure that it does not discriminate in the selection for employment or retention and promotion in employment against, or in favour, of any person on the grounds of their race or ethnic origin, marital status, sex, sexual 
orientation, gender reassignment or religion, and shall actively promote ways of employing a higher proportion of disabled people amongst its workforce.

Within the Application Form you have been asked to indicate whether you are a disabled person.  
Please read the following notes in conjunction with the application form.

Southampton City Council recognises its responsibilities in respect of disabled people and 
undertakes to:

•	comply with the employment provisions of the Disability Discrimination Act 1995;

•	give disabled applicants full and fair consideration for all vacancies;

•	provide, as practical, suitable facilities and accommodation for disabled people;

•	provide full and fair opportunities in general for the training, career development 
and promotion of disabled employees.

To ensure that its Equal Opportunities Employment Policy is working and does not 
discriminate, the Council supported by the Trade Unions considers it essential to keep up to 
date information about job applicants.  Accordingly all applicants are requested to complete 
the information on ethnic origin which will be treated as strictly confidential and used for statistical purposes only.

To help you complete the ethnic information the following categories apply:

WHITE

British
Persons born in the United Kingdom whose recent forebears came from the United Kingdom.

Irish
Persons born in Ireland whose forebears came from Ireland

BLACK OR BLACK BRITISH

Caribbean
Persons whose forebears originated in, or came from, a Caribbean island.

African
Persons whose forebears originated in, or came from, an African country.

CHINESE OR OTHER ETHNIC GROUP

Chinese
Persons whose forebears originated in, or came from, the Chinese sub-Continent including China, Vietnam etc. 

Other
Self defined groups not included in the other categories.

ASIAN OR ASIAN BRITISH

Indian
Persons whose forebears originated in, or came from, India.

Pakistani
Persons whose forebears originated in, or came from, Pakistan.

Bangladeshi
Persons whose forebears originated in, or came from, Bangladesh.

Thank you for your co-operation.

EQUAL OPORTUNITIES MONITORING FORM

The following information is required in order that the Council’s Equal Opportunities Policy can be monitored effectively.  (Please refer to guidance notes)

Please tick the box from the list below which best describes the ethnic group to which you belong:

Age | | Date of Birth | | Sex: | Male | ☐ | | Female | ☐ |
White | Black / Black British | Chinese / other ethnic group
☐ | British | ☐ | Black Caribbean | ☐ | Chinese
☐ | Irish | ☐ | Black African | ☐ | Any other background
☐ | Other White background | ☐ | Other Black background | |
| Please specify | | Please specify | | Please specify |
Asian / Asian British | Mixed |
☐ | Indian | ☐ | White & Black Caribbean | |
☐ | Pakistani | ☐ | White & Black African | |
☐ | Bangladeshi | ☐ | White & Asian | |
☐ | Other Asian background | ☐ | Other mixed background | |
| Please specify | | Please specify | | |
Do you consider yourself to have a disability? | Yes | ☐ | No | ☐
Is there anything we need to know about your disability in order to offer you a fair selection
interview?  (For example a signer or an accessible interview room) | |
How did you hear about this vacancy?
Please specify: | Job Centre | ☐ | Word of Mouth | ☐ | Website | ☐
| Advertisement (please specify) |
| Other (please specify) |

Rehabilitation of Offenders Act 1974 (exemptions) order 1975

This post is covered by the rehabilitation of Offenders Act 1974 (exceptions) order 1975 because it is a post which involves working directly with young people. You are therefore required to declare whether you have any criminal convictions (or cautions or bind overs) including those which are “spent”. The amendments to the Exceptions order 1975 (2013) provide that certain spent convictions and cautions are “protected” and are not subject to disclosure to employers and cannot be taken into account. Guidance and criteria on filtering cautions and convictions can be found on the Disclosure and Barring Service website:
https://www.gov.uk/government/organisations/disclosure-and-barring-service

Please complete the following questions, taking into account the DBS filtering guidance.

1. Do you have any convictions, cautions, reprimands or final warnings that are not “protected” defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2013)
									      Yes No

If yes, please give details including dates, on a separate sheet, place in a sealed envelope marked for the attention of the chair of shortlisting panel and enclose it with this form.

2. Are you included in any list of people barred from working with children by the Disclosure and Barring Service (DBS) or the National College of Teaching and Leadership (NCTL)?
									      Yes No

If yes, please give details including dates, on a separate sheet, place in a sealed envelope marked for the attention of the chair of shortlisting panel and enclose it with this form.

PLEASE NOTE:
•	If your application is successful, prior to taking up your post, you will be required to undergo a Formal Disclosure process through the Disclosure and Barring Service (previously CRB). This will require you to complete a separate DBS application form and to provide a range of more than one piece of documentary evidence of your identity.

•	Although a criminal record involving offences against children is likely to debar you from appointment of this type of post, the existence of other criminal convictions will not necessarily be a bar to employment.

•	Any criminal record information arising out of the disclosure process will be discussed with you before any final decision is made about your employment.

•	It is a criminal offence to apply for or accept a position (paid or unpaid) working with children if you are excluded from such work by virtue of a court order or exclusion by the DBS.

•	With effect from 17^th June 2013, criminal records certificates will only be issued directly to the applicant. Your School will request that you show them your certificate and will record the Disclosure Number and issue date and retain this on your personnel file and on its computerised personnel record system in accordance with the General Data Protection Regulations. Schools do abide by the DBS Code of Practise which does not allow for the Photo copying and retention of the full DBS Disclosure Certificate.

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