Download For Office Use Only

Personal Details
Post Applied For:
Title
Surname
Forename(s)
Address
Telephone No.
E-Mail Address
NI Number
Are you eligible to work in the UK?
Next of kin
Address
Telephone No.
Do you have a family or close relationship to a
member of staff within the Sirius Academy
Multi-Academy Trust or a member of the Governing
Body?
If yes, please give name(s) and relationship
Mobile No.
Present Post Details
Name and address of current or most recent employer:
Post held (please state if this is perm/temp)
Date of appointment
to organisation
To Post
(if different)
Notice Period
Salary/Allowance Details
Personal Statement
3 sides of A4 maximum. Please use Arial 11pt. This text box will expand as required.
Previous Employment (most recent first)
Name and address of employer
F/T
P/T
Position held
Commenced Completed
Education
Examinations in which successful
(with subjects)
Secondary School Attended
University or College attended
(with dates)
F/T
P/T
Degrees obtained
(with subjects)
Level
Pass/
Hons
Grade
Class or
Year
Division obtained
Other Professional Qualifications
Institution Attended (with dates)
F/T
P/T
Qualifications obtained
Year
obtained
Other Experience Relevant to the Post
Criminal Convictions
REHABILITATION OF OFFENDERS ACT (EXEMPTIONS) ORDER 1975
This post is exempt from the Rehabilitation of Offenders Act, 1974 by virtue of the
Rehabilitation of Offenders Act, 1974 (Exemptions) Order 1975 as amended.
Applicants must declare all convictions, cautions, reprimands or final warnings which
for other purposes are “spent” under the provisions of the Act. However, offences
which have been removed due to rules for filtering old or minor offences and are now
‘protected’ need not be declared. Further information on the filtering of offences is
available at https://www.gov.uk/government/publications/dbs-filtering-guidance
Any information given will be completely confidential and will be considered only in
relation to your application for this post. Any disclosure information revealed will be
discussed with you prior to a recruitment decision being made. In the event of
employment, any failure to disclose such information could result in dismissal or
disciplinary action.
All criminal record information is dealt with in accordance with the Disclosure &
Barring Service Code of Practice, a copy of which can be supplied on request.
A criminal record will only bar you from working with us if the circumstances
and background of your offence(s) are incompatible with the duties of the post.
Do you have any convictions,
cautions, reprimands or final warnings
that are not ‘protected’ as defined by
the Rehabilitation of Offenders Act
1974 (Exceptions) Order 1975 as
amended?
If you have answered YES above,
please state the nature of offence(s)
and the date and place of the
offence(s):
Are there any matters pending?
Any other names you have used with
dates of usage e.g. maiden name,
former marriage, change by deed poll:
References
Referees: please provide the name, address and status of two referees; one should
have direct knowledge of your professional work.
Referees will normally be contacted before interview. Please indicate here if you do
not wish this to happen:
1st Referee
2nd Referee
Name
(inc. title)
Status
Address
Tel. No.
(inc. STD)
E-mail
address
Any offer of appointment is subject to satisfactory DBS check.
Enhanced Disclosure & Barring Check.
DECLARATION
I declare that the above information is, to the best of my knowledge true and accurate.
Signed
Date
Selected at short-list stage YES/NO
For Office Use Only
Date application form received:
Date References Sent
1)
YES/NO
Interview date:
Time:
Selected after interview
YES/NO
2)
Date References returned
1)
Interview confirmed
2)
Completed Application Forms should be returned by email to:
[email protected]
EQUAL OPPORTUNITIES
We are working towards equality of opportunity for all who apply for employment with us.
We are actively opposed to discrimination and believe that monitoring our recruitment
results will help us assess any areas requiring improvement. In order to assist us with this,
we would be grateful if you would complete this form and return it with your application. It
is in no way connected with your application itself and will be separated from your
application form when it reaches our office. We undertake that this form will not be made
available to anyone involved in the recruitment and selection of staff and will remain
confidential to the Human Resources Department to be used solely for the purpose of
monitoring the effectiveness of our equal opportunities policy.
Your help in this matter is entirely voluntary and will in no way affect your application.
Please indicate your gender:
Please indicate your date of birth (dd/mm/yy):
Ethnic origin is not about nationality, place of birth or citizenship. It is to do with colour and
broad ethnic group. UK citizens can belong to any of the groups indicated below.
Would you describe yourself as:
African – Black
African – White
Asian
Bangladeshi
Caribbean – Black
Caribbean – White






Chinese

Indian

Irish

Pakistani

White

Other (please specify)

_________.
Do you have a disability?
If yes, please give details: _______________________________________________
_________________________________________________________________
Are you registered as a disabled person?
How did you hear about this vacancy? (Please specify particular publications/websites if this
is relevant)
Post applied for:
Sirius Academy West, Hull
The categories listed above are those recommended by the Commission for Racial Equality.
Thank you for your assistance.