Community SRG Ambassadors – Job Application Form Name* First Last Address* Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Personal StatementAfter 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 postPost Held*Department or Section*Date appointed* Date Format: MM slash DD slash YYYY Date finished Date Format: MM slash DD slash YYYY If applicableEmployer Name and AddressMain Duties and Responsibilities*Your Salary*Reason for leaving*Notice required to present employerCan we contact you at work?Previous Employment*Job TitleEmployer NameEmployer AddressMain DutiesDates From - ToReason 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 WorkPlease list any relevant voluntary experience you have, giving the most recent first.OrganisationMain DutiesDates From - To Life ExperienceIs 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 & TrainingPlease list any education or training (in community or school) you have undertaken and any qualification obtained.Qualifications*Subject/QualificationPlace of StudyQualification/GradeYear Obtained Other InformationDo you have a friendship or are you related to any employee/member of Trust Leeds or the Board of Trustees?*NoYesList*NameJob TitleRelationship Are you a United Kingdom or European Economic Area National?*YesNoPlease confirm your current status in terms of entitlement to work in the UK:*British CitizenOverseas National with permission to work in the UKOverseas national without permission to work in the UKHealth RecordAre 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?*NoYesIf yes, please advise us on any reasonable adjustments you may need making:*Rehabilitation of Offenders Act 1974This 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)?*NoYesIf 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.ReferencesPlease 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*NameEmail AddressAddressContact NumberOccupation At what stage can we contact your referees?*Before interviewAfter interviewAt any stageConfirmation* 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 cautionsA 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?MaleFemaleOtherIs your gender identity the same as the gender you were assigned at birth?YesNoHow do you identify your sexual orientation?BisexualGay ManGay Woman/LesbianHeterosexualOtherPrefer not to sayWhat age bracket do you fall into?Under 2526-3536-4546-5556-65Over 65What is your ethnic background?White BritishWhite IrishGypsy / Irish TravellerOther white backgroundAsian / Asian BritishBangladeshiIndianPakistaniChineseOther AsianBlack/African/Caribbean/Black BritishBlack AfricanBlack CaribbeanOther Black/Caribbean/AfricanWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOther ethnic groupDo you consider yourself disabled?NoYesWhere did you hear about this vacancy?