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Application Form Position applied for: Title: Full Name: Maiden/Previous Surname: Date of name change: Residential Status: Registered (Please select one) Are you currently on a work permit? Date of Birth: Entitled to work Licensed Date of arrival / / Yes If yes, please provide further details: / Entitled No / / Place of Birth: Email Address: Telephone Number: Have you ever been convicted of a Criminal Offence?* Mobile Number: Yes If yes, please give further details: No Address History: (Please provide all addresses where you have lived during the past five years with the most recent address first) Current Address: Date From: / Date To: / / Date To: / / Date To: / Previous Address 2: Date From: Previous Address 3: Date From: Page 1 of 3 Employment History Current Employer: Position Held: Date of Employment: / Company Benefits: Basic Salary: £ Total Package Value: Reason for Leaving: £ Notice Period: Are you currently under notice with your current employer? Yes No If yes, please provide further details: Employment History Previous Employer: Position Held: Dates of Employment: From: / To: / Company Benefits: Basic Salary: £ Total Package Value: Reason for Leaving: £ Notice Period: Employment History Previous Employer: Position Held: Dates of Employment: From: / T o: / Company Benefits: Basic Salary: Reason for Leaving: £ Total Package Value: £ Notice Period: Page 2 of 3 Where did you first see this role advertised? LinkedIn Facebook Twitter Bailiwick Express JFSC Website Other (Please only select one) Declaration Your personal candidate record will be deleted after a continuous period of 6 months if unsuccessful in your application. By completing this form you consent to the information relating to your application (including sensitive personal data) being transferred, processed and stored by the Commission and any other applicable organisations allowed by law, for the purposes stated above. *(Under the Rehabilitation of Offenders (Exceptions) (Jersey) Regulations 2002, certain jobs within the public sector are exempt from the Rehabilitation of Offenders (Jersey) Law 2001. For this particular post, you are required to declare previous convictions on this application form – regardless of whether they have been spent or not under the Law. If you are successful in your application, express permission will be requested for a police check to be made. Please note information regarding convictions will not necessarily disqualify you from consideration). If you have any concerns about the way your personal information is handled please email the Head of HR, Matt Ebbrell at [email protected] I declare that the details provided in my application are correct and complete to the best of my knowledge and I understand that enquiries may be made to verify these details. I also understand that false statements or the withholding of any relevant information may provide grounds for the rejection of my application at any stage of the appointment. Please tick this box to indicate your consent to the above. Page 3 of 3