Step 1 of 11

Position

Name:

First Last

Position applying for:

Current Employment Status:

Full Time

Part Time

Job Share

Sessional

Unemployed

Preferred Employment Status:

Full Time

Part Time

Job Share

Sessional

Essential Information

First Name(s):

Surname:

Previous Name(s):

National Insurance Number:

Address:

Street Address Address Line 2 City Postcode

Telephone (Home):

Telephone (Mobile):

Telephone (Work):

Email Address:

HCPC Registration Number: (if applicable)

Reasonable Adjustments

Please tell us if there are any reasonable adjustments we can make to assist you in your application or with our recruitment process.

Convictions

Do you hold a clean and full current UK driving licence?

Yes

Have you ever been cautioned or convicted of any offences?

Yes

Do you have any prosecutions pending?

Yes

If YES, please provide brief details:

Employment Information

Your Previous Employment

Please give us details of every job or voluntary position you have held since leaving school, including the names, addresses and dates, and reasons for leaving (continue on an additional sheet if necessary). Please indicate which of these positions involved direct work with children and young people; and explain any significant gaps in your employment history. Please do not attach a CV.

EMPLOYER

ADDRESS

DATES FROM AND TO

POSITION

REASON FOR LEAVING

If presently working, please state current salary:

Education and Training

Please give brief details of your education, qualifications and training (since the age of 16). Enclose photocopies of any relevant qualifications (continue on an additional sheet if necessary).

Education

Educational Establishment

Dates

Qualifications

Training

Dates

Title of Training

7. Other Relevant Experience

Please tell us about the other jobs you have done and the skills you used and/or learned in those jobs:

Please tell us why you applied for this job and why you think you are the best person for the job:

References

Please give the names, addresses and telephone numbers of TWO employment references, one of whom must be your present or most recent employer. Please note, we will not take up references until a provisional offer of employment is made. If an offer is made references will be contacted for written and verbal references.

Referee 1

Name:

First Last

Address:

Street Address Address Line 2 City Postcode

Telephone:

Email:

Please indicate the capacity in which this person knows/knew you and from which organisation:

Referee 2

Name:

First Last

Address:

Street Address Address Line 2 City Postcode

Email:

Telephone:

Please indicate the capacity in which this person knows/knew you and from which organisation:

Emergency Contact Details

Name of next of kin:

Relationship to applicant:

Address:

Street Address Address Line 2 City Postcode

Telephone Number (Home):

Telephone Number (Mobile):

Telephone Number (Work):

Consent to enquiries

Please note that your appointment/employment with Chrysalis Associates is dependent upon the accuracy of the information you provide, and on the receipt of satisfactory outcomes to all checks and references sought.

Please sign below to give your consent to information being obtained from the following:

Two employment referees
Present employer
Previous employers where work has entailed direct access to children / young people or vulnerable adults
Any agency with whom you have undertaken voluntary work in relation to children / young people or vulnerable adults

The Disclosure and Barring Service (this post will be subject to an enhanced disclosure from the DBS). Having a criminal record will not necessarily bar you from working with us. This will depend on the nature of the position and the circumstances and background of your offences.

I declare that all of the information given is correct to the best of my knowledge. I give consent to Chrysalis Associates Ltd to obtain information from all of the above sources with regard to my suitability to work with children/ young people.

Name:

Signature

Date:

Retention of Information

If you are successful in your application, this application form and the forms accompanying it will be stored as part of your personnel file at Chrysalis Associates. If you are unsuccessful on this occasion, Chrysalis Associates will retain your application on file for one year.

Please indicate whether you would like to be informed if another similar position becomes available within the agency:

Yes

Signed:

Date:

Any information retained by Chrysalis Associates will be stored securely, according to the requirements of the Data Protection Act, and will not be shared with any person or organization without your written consent.

All confidential waste is shredded on the premises.

Apply Online

Position

Essential Information

Reasonable Adjustments

Convictions

Employment Information

Education and Training

7. Other Relevant Experience

References

Emergency Contact Details

Consent to enquiries

Retention of Information