Application Form

Please return by email only to recruitment@leedswomensaid.org.uk
Post Applied for	OOH Team Leader
First Name	.	Last Name	.
Title Ms, Miss, Mrs etc	.	Previous last names	.
National Insurance No	.
Home Address	.
Email address	.
Home Telephone	.	Mobile Telephone	.
References
Please give the names and addresses of 2 work related/professional (paid or voluntary) referees: One should be your current employer or your last employer if you are not working at present. (Personal References or References from Colleagues will not be accepted). If you have not worked or are, for any reason, unable to provide 2 references which meet our stated criteria, please contact recruitment@leedswomensaid.org.uk to explain your situation and get advice on how you can provide acceptable references.
Referee 1	Referee 2
Name	.	Name	.
Company Name & Address	.	Company Name & Address	.
Email address	.	Email address	.
Telephone No	.	Telephone No	.
Their relationship to you	.	Their relationship to you	.
Can we contact them prior to interview?	☐ Yes ☐ No	Can we contact them prior to interview?	☐ Yes ☐ No

Employment and Work Experience

Name of Most Recent Employer	.	Post Held	.
Address	.
Telephone No.	.	Salary	.
Date Appointed	.	Period of Notice/ Date of Leaving	.
Responsibilities in This Role (please provide of brief description of your role)
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Reason for Leaving (or if still employed, reason for wanting to leave)	.
Are you considering a secondment?	☐ Yes ☐ No	If yes, have you spoken to your employer?	☐ Yes ☐ No
For full-time posts only, do you wish to job-share?	☐ Yes ☐ No
N.B. Job share arrangements will be dependent both on the nature of the role and on LWA being able to fill both vacancies.

Employment History: please start with your most recent employment or voluntary role (after the one above) and continue on a separate sheet if necessary. You may have periods where you had career breaks or gaps in employment. We’d really like to know about these to see what else you have done and what transferable skills you may have. Please include any time where you have been on sabbatical, caring for someone else, maternity, paternity, or shared parental leave, periods of unemployment, studying, or long-term travelling for example, in the last 10 years
Dates	Employer	Post and duties (Include whether paid or voluntary & how many days per week)	Reason for leaving
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Qualifications Gained and Professional Memberships Start with the most recent (Continue on a separate sheet if necessary)
Educational Establishment or Awarding Body	Qualification Gained or Professional Membership Grade	Result	Date Awarded
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Training Undertaken (please list any training courses which did not lead to a qualification) Start with the most recent (Continue on a separate sheet if necessary)
Training Provider	Title of Training Course	Result	Date Completed
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.	.	.	.
.	.	.	.
.	.	.	.

Values
Please refer to the information about LWA’s values in the information pack and explain how you feel you can demonstrate your commitment to the values listed.
Be Exceptional	.
Be Courageous	.
Be Inclusive	.
Be Inspirational	.
Be Responsive	.

Further Supporting Information
PLEASE REFER TO THE GUIDELINES ON HOW TO FILL IN THIS SECTION. Each number relates to a number of a requirement detailed on the Person Specification (in the Job Profile). Please write your answer to that criterion in the relevant numbered section below. It is essential that you demonstrate how you fulfil each one by giving examples.
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LWA is a Disability Confident Committed Employer LWA has made a positive commitment to employing disabled people under the Government’s Disability Confident scheme. We offer disabled applicants the option of requesting that their application is considered under the terms of our Guaranteed Interview Scheme (GIS). To be invited to interview/assessment under this scheme, candidates applying under GIS should be able to meet the minimum criteria as set out in the person specification for this role.
Do you wish to apply for a guaranteed interview if you meet the minimum criteria?	☐ Yes ☐ No
Whether disabled or not, do you require any reasonable adjustments to be made to enable you to attend and participate in the interview?	☐ Yes ☐ No
If you require any reasonable adjustments, please explain the nature of the adjustments required or contact recruitment@leedswomensaid.org.uk.
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Do you hold a clean, valid driving licence?	☐ Yes ☐ No
Do you speak any languages other than English? If yes, please specify which languages and your level of fluency	☐ Yes ☐ No .

Criminal Convictions
Criminal Record Checks and the Disclosure and Barring Service (DBS)
All roles within LWA require the holder to have a DBS Certificate. An application for a DBS check will be submitted for all successful candidates: for those candidates who have already revealed, or whose DBS checks reveal, criminal convictions, a full risk assessment will be carried out prior to a decision being taken as to whether or not the candidate’s record precludes her from employment with LWA. The Code of Practice on DBS checks can be found at https://www.gov.uk/government/publications/dbs-code-of-practice.
Under the Rehabilitation of Offenders Act 1974, you are required to give details of any convictions which are not spent. Failure to do so may result in Summary Dismissal.
Do you have any previous convictions or cautions?	☐ Yes ☐ No
If yes, please give details including date, sentence & nature of conviction and/or caution:
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Are you currently the subject of any criminal proceedings or police investigations?	☐ Yes ☐ No

I confirm that the information on this form is correct and gives a fair representation of my skills, experience, employment and education history. I understand that, if I am offered a post, the information submitted in my application will form part of my contract of employment and that, if it is subsequently discovered that I have wilfully or negligently given false information, I may be liable to immediate dismissal.
Signature (If you are unable to sign or provide a digital signature, please type your name and, if you are invited to interview, you will be asked to sign the form then.)	.	Date	.