APPLICATION FORM Personal Details Criminal Convictions 'We are ...

Brettenham ParkIpswich, Suffolk, IP7 7PH.Tel:01449 740252 Fax:01449 740955APPLICATION FORMPosition Applied For:Personal DetailsTitle:Forenames:Surname:Address:National Insurance No:Home Tel:Mobile Tel:Work Tel:E-mail:Post Code:Entitlement to work in the UKTo comply with the Immigration and Asylum Nationality Act 2006 all prospective employees will be asked to supplyevidence of eligibility to work in the UK. We will ask to see an appropriate official document (for example, adocument showing your National Insurance Number, birth certificate, passport etc.) Do not send these now. Furtherinformation will be sent to you if you are selected for interview.Do you require a work permit to work in the UK? Yes NoIf you already have a work permit, please give the expiry dateCriminal Convictions‘We are committed to safeguarding children and all successful applicants are required to complete DisclosureApplication Forms which means providing criminal conviction information.’Please give details of criminal convictions. You must declare any convictions and/or cautions for criminal offences,even where they are ‘spent’, (as defined by the Rehabilitation of Offenders Act 1974 and subsequent regulations)because your work will be supervising, caring for or otherwise connected with children. An Enhanced CRB check willbe required if you are selected. These details should be provided in a sealed envelope marked confidential, and returnedwith this form.Please state ‘NONE’ below if appropriate.

Education and QualificationsSchool Exam Subjects with grades and dates:SubjectGradeUniversity or College:Degree Subject:Degree & Classification:Teaching Qualifications: (where applicable)Qualification:University or College:DCSF Number:Further qualifications/degrees/professional training:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Employment History:Please list details of employment since leaving full time education until taking up your present post. Givenames employers in chronological order and include dates.EmployerDetailsInterests:

References:Title (Mr/Mrs/Ms) Initial: Surname:Address:Post Code:Telephone No:E-mail Address:In what capacity does this person know you?Title (Mr/Mrs/Ms) Initial: Surname:Address:Post Code:Telephone No:E-mail Address:In what capacity does this person know you?References:Please provide names and contact details for two referees, one of which must be your current or most recent employer.(Note: if you are not currently working with children but have done so in the past, the second referee should be theemployer by whom you were most recently employed in work with children. References will not be accepted fromrelatives or persons who only know you as a friend.Disciplinary ProceduresHave you been subject to any disciplinary procedures relating to the safety and welfare of children or youngpeople including any where the disciplinary sanction has expired?Yes/NoIf yes, please give details on the ‘Continuation Page’ of this form.

Continuation PagePlease use this page to provide any further information

Data Protection:When signing the declaration below, the applicant is confirming that they agree for Old Buckenham Hall School toprocess this information in accordance with Data Protection Guidelines for the purposes of recruitment and offeringemployment only. Old Buckenham Hall will transfer part of the information it holds to third parties where required byoperation of law. Once this form has been submitted, the applicant is entitled to see a copy of the data Old BuckenhamHall holds on the Applicant. Should the Applicant wish to see the information held by Old Buckenham Hall School,please contact The Business Manager on 01449 744798.DeclarationTo the best of my knowledge, the information I have supplied on this form is complete andaccurate.I understand that giving false information or omitting relevant information could disqualify myapplication and, if I am appointed, could lead to my dismissal.I confirm that I am not banned or disqualified from working with children nor subject to anysanctions or conditions on my employment imposed by The Independent Safeguarding Authority,the Secretary of State or a regulatory body.Signed:Date:All candidates applying for employment via e-mail will be required to sign and date this formif invited to attend an interview.‘We are committed to safeguarding children and expect all staff and volunteers to share thiscommitmentNotes:Equality Statement:Employees and prospective employees will not be unfairly discriminated against on grounds ofdisability, gender, race, colour, ethnic origin, religion, belief, culture, nationality, national origin, age,sexual orientation and trade union membership or non-membership. This list is not exhaustive and thereare other forms of discrimination that will not be tolerated.