Application Form Support Staff Durston House is committed to safeguarding and promoting the welfare of children and young people and expects all staff and volunteers to share this commitment. Please read the school’s Safer Recruitment, Selection and Vetting Policy and our Child Protection & Safeguarding Policy on our website prior to completing the application form. Position applied for: Personal Information Title Forename (s) Surname Former Name (if applicable) Preferred Name: National Insurance Number: Email Address: Home Telephone: Mobile Telephone: Address: Postcode: How long have you lived at this address? If less than 5 years please provide all previous addresses for past 5 years. Previous address: Previous address: Postcode: Postcode: Length of time at address: Length of time at address: 12-14 Castlebar Road, London W5 2DR Telephone 020 8991 6530 info@durstonhouse.org www.durstonhouse.org @durstonhouse Registered in England No. 1947995 Registered Office as above Charity No. 294670 1 General Information Are you legally eligible for employment in the UK? Do you require a work permit to work in the UK? Yes Yes No No If you know, or are related to, any current employee, pupil or governor, state the name and nature of the relationship: Academic Qualifications Please provide full details of all positions held and of all training/further education, employment, self-employment and unpaid work since leaving secondary education. Please provide explanations for any periods not in further education or training. Secondary Education Dates: From To Name of School & Address Subjects Studied - GCSE and A Level Grade/ Award Further Education Dates: From To Name of University/College & Address Course and Subjects Studied Grade/ Award 2 Professional Development (attended during the last 3 years) Dates: From To Name of Course (and award if gained) Provider Full-Time/Part- Time or Seconded Current and Most Recent Employment Please supply a full history in chronological order (with start and end dates) of all employment, self-employment and any periods of unemployment since leaving secondary education. Please provide explanations for any periods not in employment, self-employment or further education/training and in each case any reasons for leaving employment. Current Employment Name of Employer Address Title of Post Employment Dates – To and From Salary (basic) if appropriate (Please indicate spine point) Notice Period Additions (Please indicate responsibility points, London Allowance etc.) Reason for Leaving: Previous Employment Name of Employer (including full address) Dates: To and From Position Held (including subject taught and at which level) Reason for Leaving Please continue onto the next page if needed 3 Previous Employment Continued Name of Employer (including full address) Dates: To and From Position Held (including subject taught and at which level) Reason for Leaving Interests & Hobbies Please give details on your interests, hobbies or skills – in particular any which could be of benefit to the School. Miscellaneous Any further information (include any details you may consider relevant or of interest to this application) 4 Statement Please set out in detail below a statement in support of your application, which addresses the criteria in the person specification for this post. 5 References Please provide at least two professional referees. One referee should be your current or most recent employer. We will seek references for all longlisted candidates, and may approach previous employers for information to verify particular experience or qualifications, before interview. Referee 1 Referee 2 How is this person known to you? How is this person known to you? Name Address Position Tel No. Email Data Protection Name Address Position Tel No. Email The information that you provide on this form will be used to process your application for employment. The personal information that you provide will be stored and used in a confidential manner to help with our recruitment process. More details as to how we will process your data is set out in the School’s Privacy Policy which can be found on our website www.durstonhouse.org. If you succeed in your application and take up employment with the School, the information will be used in the adminis-tration of your employment. We may check the information provided by you on this form with third parties. We reserve the right to carry out an online search for shortlisted candidates. Declaration As the job for which you are applying involves substantial opportunity for access to children, it is important that you pro-vide us with accurate answers. You should be aware that the School will institute its own checks on successful applicants with the Disclosure and Barring Service (DBS), and, where appropriate, a check of the Barred List maintained by the DBS, and any offer of appointment will be made conditional on obtaining such satisfactory checks. I have not been disqualified from working with children, I am not prohibited from working with children, and I am not subject to any sanctions imposed by a regulatory body. I declare that the information I have given in this Application Form is accurate and true. I understand that providing mis-leading or false information will disqualify me from appointment or if appointed, may result in my dismissal. Signature Date Please return your completed application form to recruitment@durstonhouse.org 6