IRISH COMMUNITY SERVICES APPLICATION FORM	

PLEASE COMPLETE USING BLACK INK OR TYPE.
APPLICATION FOR THE POST OF:       Carers Co-ordinator                                                   	 	

SURNAME:       

TITLE:  	FORENAME(S):       

Please give details of any previous surnames:       
	
ADDRESS:	TELEPHONE NUMBERS	

POSTCODE:       

E-MAIL ADDRESS:       					
	HOME:       

WORK:       

May we contact you at work?  

MOBILE:       							

     	
NATIONAL INSURANCE NUMBER: 						

EMPLOYMENT HISTORY	
	
PRESENT OR MOST RECENT EMPLOYMENT 	
Name & address of employer:

Nature of business:       	Job title and summary of main duties:

Date of appointment: mm/yyyy
	Salary Scale and Current Salary:       	
Reasons for leaving (If applicable):       	Notice required:      	

PREVIOUS EMPLOYMENT 
Please summarise your employment history since leaving full-time education, paid or unpaid, or voluntary work for an organisation or agency, full or part-time.   Start with the most recent.  Please continue on a separate sheet if necessary.	
Employer’s name and address	From
Month / Year	To
Month / Year	Job title and summary of main duties	Reasons for Leaving  	

     	     	     	     	     	

Please give details of any gaps in your employment history  

													

QUALIFICATIONS AND TRAINING	
	
EDUCATIONAL AND ACADEMIC QUALIFICATIONS:  Please give details of your education with examination dates, results and qualifications obtained.  Please include any training and membership of professional bodies, relevant to the application. (Please continue on a separate sheet if necessary)  Evidence of qualifications may be requested.	
School, College, University	Examination, course
(with dates)	From	To	Result/Qualifications gained	

     	     	     	     	     	
IN-SERVICE TRAINING	Give details of the most recent, relevant courses attended and indicate any awards earned 	
Course Title

	Provider  

	Duration

	Dates

     	     	     	     	

REFERENCES	
	
Give details of two people who have knowledge of you in a working / educational environment, paid or unpaid.  The first reference should be your present or most recent employer.    We will take up references after we make an offer of employment.	
If you were known to either of your referees by another name please give details:

Your first referee:		 								Your second referee:			
1.			2.			
Name:	     		Name:	     		
Position:	     		Position:	     		
Address:	     		Address:	     		
Tel:	     		Tel:	     		
In what capacity does the referee know you?
		In what capacity does the referee know you?

	

INFORMATION IN SUPPORT OF YOUR APPLICATION	
	
Please use this section to say why you are applying for this job, in particular how your personal skills, knowledge and experience will enable you to perform the duties detailed in the job description and personal specification.   Include details of any work or other experience you have which may be relevant to your application, including voluntary work and leisure interests.   Please continue, if necessary, on the back page or on further sheets which must be attached securely to this form.

ADDITIONAL INFORMATION	

To comply with the Asylum and Immigration legislation during the selection process you will be required to give evidence of your ability to work in the UK.  Do you need a work permit to work in the UK?   				yes/no	

Under the Working Time Directive, you should not work more than 48 hours a week. Do you plan to undertake work for other employers, which would cause a breach of these regulations  	yes/no	

 If so, please give details: 	
	
 Do you hold a full current driving licence?   	yes/no	

Do you have access to a car which you could use for work?	yes/no	

Are you a relative or partner of any Trustees or employee of ICS?	yes/no	

If YES, please state name of person and relationship: 		
Do you have a physical or mental impairment which has a substantial over more than 6 months or have a long term effect on your ability to carry out day to day activities?                                                                 
YES/NO   
                                                         
If you have a disability please let us know of any special arrangements you may need to make if you are short listed for interview:  

Please list any disease, disorders, and allergies, muscular or musculoskeletal injuries from which you have suffered or do suffer.

Please detail any form of medicine, drugs or treatment you are currently and/or regularly receiving.

Where did you see the advertisement for this post?  If seen on the internet on which site?		

How many working days have you lost due to sickness absence over the past twelve months? 		

Criminal Convictions – Rehabilitation of Offenders Act 1974	
	
In applying for this post with Irish Community Services, you are required to disclose any unspent convictions that you have received, and any prosecutions pending against you.  (You do not need to include any that are “spent” under the Rehabilitation of Offenders Act 1974.)

Do you have any unspent criminal convictions?                      	 Yes □   No  □ (tick as appropriate)

If you answer yes, you will be required to provide written details of the unspent conviction(s) or offence(s) should you be selected for interview.  Please ensure that you bring these with you if you are invited to interview.  	
Signed:		Date: dd/mm/yyyy 	

DECLARATION	
	
I agree that any offer of employment with Irish Community Services (ICS) is subject to satisfactory evidence of the right to work in the UK, satisfactory references and medical clearance. In accordance with the 1998 Data Protection Act, it is agreed that Irish Community Services may hold and use personal information about me for personnel reasons and to enable the organisation to keep in touch with me.  This information can be stored in both manual or computer form, including the data in Section 2 of the Data Protection Act 1998.

I confirm that the information given in this application and any attachments is factually correct and complete and I understand that any false information may, in the event of employment, result in disciplinary action or dismissal by Irish Community Services..
	
Signed:  	Date: dd/mm/yyyy	
					
Please note that if you e-mail this application and are subsequently invited to an interview, you will be asked to sign this form.

Please email your completed form to director@irishcommunityservices.org.uk have not been contacted within 2 weeks of the closing date, you must assume that your application has, on this occasion, been unsuccessful.

RECRUITMENT MONITORING	
	
Irish Community Services operates a Diversity Policy and is committed to appointing the best candidate, on the basis of their ability to do the job.   The Codes of Practice published by the Equal Opportunities Commission and the Commission for Racial Equality advise employers to monitor the outcome of selection decisions to ensure that discrimination does not occur within our recruitment and selection process.  The information you give is confidential and is used for monitoring purposes only.  It is not part of the selection process.	
Application for the post of:       	
Job Reference No:       	
Full name:       	
Gender (please select as appropriate)  	Female  □	Male □	
Do you consider yourself to have a disability?		
If yes, what is the nature of your disability?
     	
Are you a Carer for a partner, relative or friend ?	
If yes, please indicate the average time spent Caring per week	1 - 19 hrs
20 – 34
35 - 49 hrs
> 50 hrs	□
□
□
□					

How would you describe yourself?  
These categories of ethnic origin are recommended by the UK Equal Opportunities Commission as the most appropriate for the UK.  We recognise however that the specified categories may not be appropriate for everyone.  If this is the case, please use the last box.  *  Please define.	
Please tick the appropriate box to indicate your cultural background:	
White:	
British	□	Irish	□	Other:	
Mixed:	
White and Black Caribbean	□	White and Black African	□	White and Asian 	□	
Asian or Asian British:	
Indian	□	Pakistani	□	Bangladeshi	□	Asian 
Other	□	
Black or Black British:	
Caribbean	□	African	□	Black Other	□			
Chinese or Other Ethnic:	
Chinese	□	Chinese Other	□	Other Ethnic Group	□		
INFORMATION IN SUPPORT OF YOUR APPLICATION (continued)