Streetwise Application Form

APPLICATION FORM This form has been designed to seek only that information which is consistent with equal opportunities employment procedure. On receipt of your application this page will be detached and filed separately. None of the people responsible for short listing will see Part A until short listing has been completed. The information from Part B will be kept in statistical form only; after the information has been recorded Part B will be destroyed. It will not be used in any of the short listing, interviewing or selection process. Completion of Part B is optional and in no way affects your application.

OFFICE USE ONLY

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PART A Application for the post of ………………………………………………………………………. NAME …………………………………………………………………………………….…….. ADDRESS ………………………………………………………………………...…………….. ……………………………………………………………………………………. ………………………………………………………………………………………………………… …………. ……………………………………………………………………………………………………. TELEPHONE ………………………..(day) ……………………….……………….…(evening) To the best of my knowledge the information I have given is correct.

SIGNED …………………………………….. DATE ………………………………………….. PART B

Equal Opportunities Monitoring Form

African ( ) African –Caribbean ( ) Bangladeshi ( ) Pakistan ( ) Indian ( ) Chinese ( ) Black British ( ) Mixed Race ( ) White European ( ) Other (please specify)…………………….. Age: Under 25 25 – 34 35 – 44 45 – 54

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Would you describe yourself as having a disability ? Yes ( ) No ( ) Gender: Female ( ) Male ( )

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Over 54

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Please state where you heard about this job …………………..

PART C OFFICE USE ONLY ( ) Please give your employment history, starting with the most recent, including any part-time or voluntary activity. Organisation and Address

Job Title and Brief Description of Duties

Status Date (i.e. FT/PT Started voluntary, placement etc.)

Date Reason finished for Leaving

Salary

PART D Please give details of any relevant training completed or qualifications attained, starting with the most recent. Continue on a separate sheet if required. Course Title & Educational Institution

Qualifications

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Date Completed

OFFICE USE ONLY ( ) PART E Please read the Person Specification carefully and use the space below to explain why you would like to work at Streetwise, demonstrating that you have the skills, knowledge and experience for the position. Continue on a separate sheet if required.

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OFFICE USE ONLY (

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PART F SICKNESS Have you had any periods of absence during your employment history of one week or more? YES

NO

If yes, what was the reason for your absence ……………………………………………………. PART G REFERENCES We may wish to take up references prior to interview, please let us know if this would cause a problem. Please give the names of two referees, one of whom should be able to comment on your practice. NAME ADDRESS

Telephone No. Relationship to you:

NAME ADDRESS

Telephone No. Relationship to you: Please return the completed application form to Streetwise 35 – 37 Groat Market Newcastle NE1 1UQ

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