Name of Organisation Contact address Type of organisation Sector Postcode Country V Primary contact Alternative contact Name Name Position Position Telephone number Telephone number Mobile number Mobile number Email Address Email Address Part 9: Declaration W To be signed by the person making the referral I confirm that to the best of my knowledge the information in this form is accurate and that I have provided all documents legally required and any other relevant documentation. I understand that the DBS may contact me about the information I hold on the person I have referred. I understand that any information I have referred will be used by the Disclosure and Barring Service and may be disclosed to the referred person or other parties in accordance with statutory duties under the Safeguarding Vulnerable Groups Act 2006 and other legislation. Signature Position Name (in CAPITALS) Organisation Date Relationship to the individual you are referring X Returning the form Please check that you have answered all the questions you Please return the form to: can and signed the Declaration. Disclosure and Barring Service This form should be returned, together with all supporting PO Box 181 documentary evidence, to the address opposite. Darlington DL1 9FA
Name of Organisation Type of organisation Sector Contact address Postcode Country V Primary contact Alternative contact Name Position Telephone number Mobile number Email Address Name Position Telephone number Mobile number Email Address Part 9: Declaration W To be signed by the person making the referral I confirm that to the best of my knowledge the information in this form is accurate and that I have provided all documents legally required and any other relevant documentation. I understand that the DBS may contact me about the information I hold on the person I have referred. I understand that any information I have referred will be used by the Disclosure and Barring Service and may be disclosed to the referred person or other parties in accordance with statutory duties under the Safeguarding Vulnerable Groups Act 2006 and other legislation. Signature Name (in CAPITALS) Date Position Organisation Relationship to the individual you are referring X Returning the form Please check that you have answered all the questions you can and signed the Declaration. This form should be returned, together with all supporting documentary evidence, to the address opposite. Please return the form to: Disclosure and Barring Service PO Box 181 Darlington DL1 9FA
dbs-referral-form-57217.docx