Declaration of Criminal Convictions, Cautions & Bind-Over Orders In Confidence 1.Are you included in the Adult’s Barred List? YES NO (if yes please give details) 2. Do you have any cases pending? YES NO (if yes please give details) 3. Do you have any convictions, cautions, informed warnings, diversionary youth conferences or bind-over orders that are not subject to (as defined ‘filtering’ by the Rehabilitation of Offenders (Exceptions) Order (NI) 1979, as amended in 2014)? YES NO If yes, please provide details below, giving as much information as you can, including, if possible, the offence, the approximate date of the court hearing and the court which dealt with the matter. 4. Have you ever been the subject of an Adult Abuse investigation which alleged that you were the perpetrator? YES NO If yes, please list full details below including the name of police unit or HSC Trust involved in the investigation. If possible please provide the approximate date/s. Declaration and Consent: I declare that the information I have given is complete and accurate. I understand that I will be asked to complete an Access NI Disclosure Certificate Application form if I am considered to be the preferred candidate. I consent to the appropriate Access NI check being made and I agree to enquiries relevant to this declaration. Signature: ____________________________________ Date: ______________________ Print Name: __________________________________ Any Surname previously known by: __________________________________
Declaration of Criminal Convictions, Cautions & Bind-Over Orders In Confidence 1.Are you included in the Adult’s Barred List? (if yes please give details) YES NO 2. Do you have any cases pending? (if yes please give details) YES NO 3. Do you have any convictions, cautions, informed warnings, diversionary youth conferences or bind-over orders that are not subject to ‘filtering’ (as defined by the Rehabilitation of Offenders (Exceptions) Order (NI) 1979, as amended in 2014)? YES NO If yes, please provide details below, giving as much information as you can, including, if possible, the offence, the approximate date of the court hearing and the court which dealt with the matter. 4. Have you ever been the subject of an Adult Abuse investigation which alleged that you were the perpetrator? YES NO If yes, please list full details below including the name of police unit or HSC Trust involved in the investigation. If possible please provide the approximate date/s. Declaration and Consent: I declare that the information I have given is complete and accurate. I understand that I will be asked to complete an Access NI Disclosure Certificate Application form if I am considered to be the preferred candidate. I consent to the appropriate Access NI check being made and I agree to enquiries relevant to this declaration. Signature: ____________________________________ Date: ______________________ Print Name: __________________________________ Any Surname previously known by: __________________________________
Employment%20Application%20-%20CL0618.docx