PRIVATE AND CONFIDENTIAL APPLICATION FORM PERSONAL DETAILS Page 1 of 14

For Office use Only
Date received ………………………….
Applicant number ……………………..
PRIVATE AND CONFIDENTIAL
APPLICATION FORM
POST:...............................................................................................................................
PERSONAL DETAILS
TITLE: ………………………………………………………………………………………………………...............
SURNAME: …………………………………………………………………………………………………..............
FORENAMES: ………………………………………………………………………………………………………...
ADDRESS: …………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………..
CONTACT TELEPHONE NUMBER: ……………………………………………………………………..............
ALTERNATIVE CONTACT NUMBER ……………………………………………………………………………..
EMAIL ADDRESS ……………………………………………………………………………………………………
For part-time posts, days available for work:………………………………………………………………………
If selected, when could you start? ………………………………………………………………………………….
How did you hear about the position? ……………………………………………………………………………..
Do you require a work permit to allow you to work?
Do you have a full driving licence and access to a car?
YES / NO
YES / NO
Page 1 of 14
Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
Secondary School
EDUCATION & TRAINING
School Qualification and Date Awarded Grade
Further and Higher Education (please continue on a separate sheet if necessary)
Educational
Establishment(s)
Qualifications and Date Awarded
(please state main subject areas)
Grade
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Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
EDUCATION & TRAINING
Membership of Professional Bodies (Higher Education Academy, Nursing, Accountancy, or similar)
Name of Body
Membership Number
Level of Membership,
e.g., Graduate,
Chartered, Fellow, etc
Other relevant training or skills gained (including short courses and seminars)
Please describe any other relevant skills gained or training courses completed
Skill or Training Topic
Where, when or how did you develop this skill or acquire this
training?
Page 3 of 14
Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
EMPLOYMENT HISTORY
Present or Most Recent Employer ……………………………………………………………………………...
Address …………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
………. ……………………………………………………………………………………………………………..
Job Title…………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
Salary ……………………………………………….
Dates employed:
from …………………….
to ………………………..
Notice required ……………………………………………………………………………………………………
Please tell us about your current duties and responsibilities and about the skills you use and/or have
learned in this job. (Please continue on a separate sheet if necessary).
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Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
Past Employment
Please list all previous employment, starting with the most recent. Please explain any gaps in
employment history. (Please continue on a separate sheet if necessary).
Employer Job Title Dates
From – To
Outline of Duties
Salary
Page 5 of 14
Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
PERSONAL STATEMENT
This is your opportunity to tell us how your experience and abilities make you a suitable candidate for this
post. Please refer to the job descritption and the person specification, taking into account the essential
and desirable criteria, please be as specific as possible e.g., do not answer ‘I have knowledge of
children’s services’. Use this space to provide any other information you wish us to consider, which has
not already been provided elsewhere. This could include relevant experience and abilities gained during
gaps in paid employment, for instance, through voluntary work and or community activities.
You may continue on a separate sheet if necessary.
Page 6 of 14
Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
REFERENCES
Please give details of two people who can be contacted for a reference. One should be your present or
most recent employer. References will be taken up after interview, if you are still being considered for
employment.
Referee 1
NAME…………………………………………………………………………………………..
ADDRESS …………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………….....................
OCCUPATION………………………………. DAYTIME PHONE…………………………
EMAIL:………………………………………………………………………………………….
How do you know him/her? ………………………………………………….....................
Referee 2
NAME…………………………………………………………………………………………..
ADDRESS …………………………………………………………………………………….
………………………………………………………………………………………………….
………………………………………………………………………………….....................
OCCUPATION………………………………. DAYTIME PHONE…………………………
EMAIL………………………………………………………………………………………….
How do you know him/her? …………………………………………………....................
I declare that to the best of my knowledge the information provided by me on this form and any
supporting documentation that I have provided has been filled in fully and accurately. I authorise CSM to
check the information I have supplied and if offered the post to carry out a Criminal Record Bureau Check
(CRB). If I am appointed, I understand that if the information I supply is not accurate or is false, you could
withdraw an offer of employment or dismiss me. I understand that if I do not agree with this declaration
you cannot consider my application.
Signed……………………………………………………
Date …………………………………………………..
Please send completed form to:
Carers Support Merton
The Vestry Hall
336-338 London Road
Mitcham, Surrey CR4 3UD
Tel: 020 8646 7515
info@csmerton.org
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Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
RIGHT TO WORK IN THE UK
In order to be considered for a role with Carers Support Merton you will need to sign this
form to confirm that you have the right to work in the UK.
You will be required to provide ONE of the documents listed below if you are shortlisted
for an interview.
1. A passport showing that you are a British citizen
2. A UK passport showing that you have the right of abode in the UK
3. A national passport or national identity card showing that you are a national of a
European Economic Area (EEA) country of Switzerland
4. A residence permit issued to you from a European Economic Area (EEA) country
or Switzerland
5. A passport or other document issued by the Home Office which has an
endorsement stating that you have current right of residence in the United
Kingdom
6. A passport or other travel document endorsed to show that you are exempt from
immigration control, can stay indefinitely in the United Kingdom, or have limit on
your stay
7. A passport or other travel document endorsed to show that you can stay in the
United Kingdom – and that this endorsement allows you to do the type of work
we are offering provided it does not require a work permit
8. If you are an asylum seeker, please provide an Application Registration Card
issued by the Home Office stating that you are permitted to take up employment
I confirm that I have the right to work in the UK and will be able to produce one of the
documents listed above.
Name…………………………………………………………………………………
Signature…………………………………………… Date………………………..
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Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
OTHER PERSONAL INFORMATION
REHABILITATION OF OFFENDERS ACT (EXCEPTIONS ORDER) 1975 AS AMENDED
Post Applied for:
Reference No:
Because of the nature of the work for which you are applying, you must provide information
about any criminal convictions, spent or unspent. In the event of you being employed as a result
of this application, any failure to disclose such convictions could result in dismissal or
disciplinary action.
Have you been convicted of a criminal offence?
YES / NO
If yes, please complete, sign and date the attached Criminal Convictions Declaration Form.
In addition to the above and because of the nature of work carried out by the
organisation, please confirm if you have ever been interviewed in connection with, or
been the subject of any abuse investigation or enquiry.
YES / NO
This document will be kept separate from your application form; the information you
provide will be treated in the strictest confidence and will not be available to members of
the appointment panel.
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Page 1 of 4
Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
CRIMINAL CONVICTIONS DECLARATION FORM
REHABILITATION OF OFFENDERS ACT 1974 (EXCEPTIONS ORDER) 1975 AS AMENDED
All candidates should complete this form. Seal it in the enclosed envelope and return
it with your application. The envelope will be opened only for the successful
candidate. All other forms will be destroyed, unopened, immediately following
acceptance of the post by the successful candidate. Appointments will not be
confirmed till relevant information has been checked.
Guidance Note
Candidates with no previous convictions
Please complete sections A, C and D fully.
Candidates previously convicted of a criminal offence.
1. The terms of the Act mean that for most posts you may be entitled to withhold
information on a criminal conviction on the grounds that is “spent” or forgotten
following a specified period of rehabilitation (see information overleaf). In this
case you may answer “no” to the declaration for “spent” convictions, and you
should answer “yes” for any convictions not yet “spent” and answer all other
relevant sections fully.
2. If the post is EXCEPTED under the act, this will have been specified in the job
description. In this case, you are not entitled to withhold information on any
convictions on the grounds that they are “spent” under the Rehabilitation of
Offenders Act 1974 and must answer yes to the declaration, and provide full
answers to the other sections.
A. Declaration
Have you ever been convicted of a criminal offence? Yes No
Do you have a court appearance pending or have you been charged by the Police for
a criminal offence? Yes No
B. Additional Details (to be completed if you answered yes in any part of the above section).
Continue on a separate sheet if necessary.
Date Court Details of Offence Sentence
Page 2 of 4
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Registered Charity Number: 1085761 Company Number: 4164966

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Date received ………………………….
Applicant number ……………………..
C. Former Names and Addresses (the information should be completed by all candidates).
Continue on a separate sheet if necessary.
Name Address Date From - To
D. (this information should be completed by all candidates)
I certify that
1. I have read the Guidance note above
2. I have not withheld information that may affect my application for appointment
3. I understand that false information or omissions may lead to dismissal
4. I understand you may take steps to verify the information provided
Signed: …………………………………………………………….
Name: ……………………………………………………………..
Date ………………………………………………………………..
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Registered Charity Number: 1085761 Company Number: 4164966
Page 3 of 4

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Date received ………………………….
Applicant number ……………………..
How do I know if my conviction is "spent"?
This depends on the sentence given. For a custodial sentence, the length of time
actually served is irrelevant. The rehabilitation period before a conviction is "spent" is
decided by the original sentence.
SENTENCES OF MORE THAN 2 ½ YEARS CAN NEVER BECOME SPENT
Other sentences become spent after fixed periods from the date of conviction. Below
are some examples.
Sentence
Prison (immediate or suspended
sentence) or youth custody more than
6 months and not exceeding 2 ½
years.
Prison (immediate or suspended
sentence) or youth custody 6 months
Rehabilitation Period
People aged 18 or
over when convicted
10 Years 5 years
People under 18
when convicted
7 Years 3 ½ Years
or less
Fine or Community Service Order 5 Years 2 ½ Years
Absolute Discharge 6 Months 6 Months
Detention Centres 3 Years 3 Years
With some sentences the rehabilitation period varies:
Sentence
Probation, supervision, care order,
conditional discharge, or bind-over
Attendance Centre Orders
Hospital Orders (with or without a
restriction order)
Rehabilitation
1 year or until the order expires,
whichever is longer.
1 year AFTER the order expires
5 years, or 2 years after the order
expires, whichever is longer.
Page 12 of 14
Registered Charity Number: 1085761 Company Number: 4164966

For Office use Only
Date received ………………………….
Applicant number ……………………..
EQUAL OPPORTUNITIES MONITORING FORM
Post Applied for:
Reference No:
Carers Support Merton is committed to the successful development of an Equal Opportunities
Policy. Staff are selected on merit, irrespective of race, sex, disability or age. In order to
monitor the effectiveness of our Equal Opportunities Policy Carers Support Merton requests that
all applicants complete this form. In accordance with the Data Protection Act 1998, the
information you have provided will only be used for the purposes of equality monitoring. The
information will be used in summary form only and may inform improvements to our Equal
Opportunities Policy.
Question 1 Please
tick Female Male Transgender
Question 2 Please
Age group:
tick
16-25 26-35 36-45 46-55 56-65 Over 65
Question 3
What is your ethnic
group?
Local Authorities are
required to monitor
their ethnic group of
their workforce.
These categories are
recommended by the
Commission for
Racial Equality and
have been used in
the recent census.
Question 4 Disability
White British
White Irish
White - any other background, please write in
Mixed White and Black Caribbean
Mixed White and Asian
Mixed - any other mixed background, please write in
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian - any other background, please write in
Black or Black British Caribbean
Black or Black British African
Black or Black British – any other background,
please write in
Chinese
Any other background, please write in
I do not wish to identify at this stage
Do you have a disability?
Please
tick one
category
The Disability
Discrimination Act
(DDA) 1995 makes it
unlawful to
discriminate against
current or prospective
employees
No Yes I do not wish to identify
Please tick one of the following:
Hearing Impairment Speech Impairment
Visual Impairment Mental Health
Learning Difficulties Dyslexia
Diabetes
Physical Disabilities
Progressive Condition (i.e. cancer, HIV)
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Registered Charity Number: 1085761 Company Number: 4164966

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Date received ………………………….
Applicant number ……………………..
Other – please specify:
Question 5
Is there anyone who
relies on you for day
care and attention?
Question 6 Please
tick
Sexual Orientation
Definition of disability under the DDA is ‘A physical or mental
impairment which has a substantial and long term adverse
effect on a person’s ability to carry out normal day to day
activities’.
No
If yes, are they:
Yes
a) Children under 16 b) Sick or elderly relative or friend
Bisexual
Gay man
Gay women/lesbian
Heterosexual/straight
Other, please write in
I do not wish to identify
This document will be kept separate from your application form; the information you
provide will be treated in the strictest confidence and will not be available to members of
the appointment panel. Please seal in separate envelope provided.
Page 14 of 14
Registered Charity Number: 1085761 Company Number: 4164966