Community SRG Ambassadors – Job Application Form

Name*

First Last

Address*

Street Address Address Line 2 City County Post Code Country

Phone*

Email*

Personal Statement

After reading the job description and details please complete this section. Please show us how you meet the required skills and experiences, giving examples to show us your suitability for this role. And please outline how and why you feel you can deliver on the role’s responsibilities (giving examples of what you’ve achieved in similar roles, or through your volunteering or community participation).

Present or last post

Post Held*

Department or Section*

Date appointed*

Date finished

If applicable

Employer Name and Address

Main Duties and Responsibilities*

Your Salary*

Reason for leaving*

Notice required to present employer

Can we contact you at work?

Previous Employment*

Job Title	Employer Name	Employer Address	Main Duties	Dates From - To	Reason for Leaving

Please list any relevant paid employment you have had, giving the most recent first. Click the plus at the end of the row to add more.

Voluntary and Unpaid Work

Please list any relevant voluntary experience you have, giving the most recent first.

Organisation	Main Duties	Dates From - To

Life Experience

Is there anything else you have done that you wish to tell us about? This may include work experience, unemployment, caring for a child/relative/friend, etc.

Education & Training

Please list any education or training (in community or school) you have undertaken and any qualification obtained.

Qualifications*

Subject/Qualification	Place of Study	Qualification/Grade	Year Obtained

Other Information

Do you have a friendship or are you related to any employee/member of Trust Leeds or the Board of Trustees?*

List*

Name	Job Title	Relationship

Are you a United Kingdom or European Economic Area National?*

Please confirm your current status in terms of entitlement to work in the UK:*

Health Record

Are you aware of any health reasons which may impact on your ability to apply for, or deliver, this post either at application or the interview stage?*

If yes, please advise us on any reasonable adjustments you may need making:*

Rehabilitation of Offenders Act 1974

This post is exempt from the provision of Sector 4 (2) of the Rehabilitation of Offenders Act 1974. You are not entitled to withhold any information about convictions, including any cautions, which for the purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation to your application for this post.

Have you at any time received, or have pending a court conviction (including any cautions)?*

If yes please give details:*

Failure to disclose all convictions, including “spent” ones, will lead to your application form being disqualified, or if you are appointed to your dismissal. If the post you are applying for involves substantial access to children and/or other specific vulnerable groups, Trust Leeds will check with the DBS Disclosure Service for existence and content of any criminal record if you are offered the post.

References

Please remember to ask your referee(s) for permission before you give their name. Please give the names, addresses and telephone numbers of two referees. If you are or have been employed these should include your most recent employer, your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for this post. Volunteer co-ordinators and character references are also acceptable. Family members or relative cannot be referees.

If you are a student please provide contact details of a teacher at your school, college or university.

If you have not been in employment for a considerable amount of time but have previous employment then you should seek one reference from your last employer and a personal reference (family members or relatives cannot be referees).

References*

Name	Email Address	Address	Contact Number	Occupation

At what stage can we contact your referees?*

Confirmation*

I have read this statement and confirm that all information given by me is correct.

I understand that appointment will be subject to the information given in this form being correct and that canvassing or failure to disclose a relationship to a member of Trust Leeds staff/Board of Trustees will disqualify. To withhold, falsify or omit relevant information may lead to disciplinary action, including dismissal, in the case of a successful applicant.

Check on convictions or cautions

A check as to the existence and content of a criminal record will be requested from the Disclosure and Barring Service after a person has been selected for appointment to this post. Refusal to agree to a check being made could disqualify you from being considered for the appointment.

You are therefore asked to sign the statement below to confirm your agreement, if you are selected for the appointment, to a check being made on any criminal record applicable to you.

Please give details on the application form of all convictions, cautions, reprimands or warnings (whether spent or not)

Consent*

I agree, if I am selected for this appointment, to checks being made with the Disclosure and Barring Service for any record of convictions or cautions against me.

I am aware that such information as appropriate for Enhanced Disclosures will be made available.

Equality & Diversity (Optional)

We are committed to employing a workforce that reflects the community we serve. In order to monitor our progress, we ask you to answer the questions below.

If you do not wish to complete all or any part of this monitoring form, you do not have to do so.

What is your gender identity?

Is your gender identity the same as the gender you were assigned at birth?

How do you identify your sexual orientation?

What age bracket do you fall into?

What is your ethnic background?

Do you consider yourself disabled?

Where did you hear about this vacancy?