Rehabilitation of offenders act 1974 (Exemptions Order 1975) The nature of the work you are applying for could involve direct contact with vulnerable people and we are obliged to ask you, in connection with this application, to disclose any convictions you may have. Under the conditions of the above Order you are not entitled to withhold information about convictions which might otherwise be regarded as In the event of employment, failure to disclose such convictions could “spent”. result in dismissal or disciplinary action. Would you be willing to undertake a Disclosure and Barring Service check? Yes No Equality and Diversity Monitoring Healthwatch Dudley is committed to a policy of ensuring equality of opportunity in employment for all. The information below will be used for monitoring purposes and will be treated confidentially. All unsuccessful application forms are destroyed after six months. 1. Which of the following options best describes how you think of yourself? Male Female 4. Do you have any form of disability? Yes No If yes, please give details ____________________________________________________________________________________ 3. Which of the following options best describes how you think of yourself? Please tick the appropriate box 1 White UK 6 Bangladeshi 2 White Irish 7 Chinese 3 Other (please specify) 8 Indian 9 Pakistani 4 Black African 10 Other (please specify) 5 Black Caribbean did you see the position advertised? Newspaper Which one? Website Which one? E-bulletin Which one? Twitter Which one? Other Please give details: If completing this form online please print off and sign this sheet and send to us by post (we must receive your emailed application before the deadline, but the printed sheet can arrive after) I declare that the information in this form is true and complete I understand that any wilful – misstatement or omission renders me liable to disciplinary action if appointed. Signature: Name in capital letters: Date:
Rehabilitation of offenders act 1974 (Exemptions Order 1975) The nature of the work you are applying for could involve direct contact with vulnerable people and we are obliged to ask you, in connection with this application, to disclose any convictions you may have. Under the conditions of the above Order you are not entitled to withhold information about convictions which might otherwise be regarded as “spent”. In the event of employment, failure to disclose such convictions could result in dismissal or disciplinary action. Would you be willing to undertake a Disclosure and Barring Service check? Yes No Equality and Diversity Monitoring Healthwatch Dudley is committed to a policy of ensuring equality of opportunity in employment for all. The information below will be used for monitoring purposes and will be treated confidentially. All unsuccessful application forms are destroyed after six months. 1. Which of the following options best describes how you think of yourself? Male Female 4. Do you have any form of disability? Yes No If yes, please give details ____________________________________________________________________________________ 3. Which of the following options best describes how you think of yourself? Please tick the appropriate box 1 White UK 6 Bangladeshi 2 White Irish 7 Chinese 3 Other (please specify) 8 Indian 9 Pakistani 4 Black African 10 Other (please specify) 5 Black Caribbean did you see the position advertised? Newspaper Which one? Website Which one? E-bulletin Which one? Twitter Which one? Other Please give details: If completing this form online please print off and sign this sheet and send to us by post (we must receive your emailed application before the deadline, but the printed sheet can arrive after) I declare that the information in this form is true and complete – I understand that any wilful misstatement or omission renders me liable to disciplinary action if appointed. Signature: Name in capital letters: Date:
Application-Form-Board-Aug-2018.docx