CONFIDENTIAL - Application Form
The University is an Equal Opportunity Employer

This application form must be typewritten.  Application forms received after the closing date will not be considered.  Do not enclose a curriculum vitae as it will not be used as part of the shortlisting process.  Applications for employment are treated with the utmost confidentiality, subject only to normal legal requirements.  

Position applied for: Professional and Academic Tutor, DECAP 	Reference No: 220517	
	
School/Department:  Psychology	Closing Date: Monday, 12 June 2017  to arrive by 4pm	

Personal Details		
		
	Title		______________________	
	Forename		______________________	
	Forename 2		______________________	
	Surname		______________________	
	Email Address		______________________

Address	
	
Please add your correspondence address:	
	
	Address Line 1		_______________________	
	Address Line 2		_______________________	
	Address Line 3		_______________________	
	Address Line 4		_______________________	
	Postcode		_______________________	
	Country		_______________________

Contact Details	
	
Please add your home telephone number below and mobile number if applicable.	
	
			____________________________________________________

Media	
	
Please specify the publication or website where you initially saw this post advertised if applicable	
	
	Media Name		_______________________

Education and Qualifications	

Starting with the most recent, please give details of your education and training (original certificates or other authentic evidence of your qualifications will be required if you are recommended for appointment). Where you are relying on equivalent qualifications please ensure that you detail how these meet the stated criteria. Where insufficient space is provided, please expand the boxes or attach a separate sheet	

Place of Learning	Study Commencement Date	Qualification Date Obtained	Study Expected end date	Subject	Qualification Level (Other)	Qualification/ Achievement /  Grade	Grade	Grade (Other)	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	

Additional / Equivalent Qualification Information	

	Additional / Equivalent Qualification		_____________________________________________________	
	Information

Professional Qualifications and Memberships of Professional	

Please give details of any professional qualifications and memberships that are relevant to this application	

Professional Body/Institution:

 	

Date Qualification Achieved: 	

Date of Membership: 	

Level of Membership: 	

    	    	    	    	

    	    	    	    	

    	    	    	    	

Training	

Please give details of any training courses undertaken that are relevant to this application	

From: 

	

To: 	

Name of Training Course: 	

Result: 	

Date Awarded: 	

    	    	    	    	    	

    	    	    	    	    	

    	    	    	    	    	

Employment History	

Please provide details of all positions held since completing your full-time education, starting with your most recent position.  Please also give details of any gaps in paid employment e.g. voluntary work / caring responsibilities.

Name, Address & Postcode
of Employer	Employment
Start Date	Employment
End Date	Job Title	Job Details	Reason for Leaving	

						

					

					

					

					

Name, Address & Postcode
of Employer	Employment
Start Date	Employment
End Date	Job Title	Job Details	Reason for Leaving	

						

						

						

					

						

						

Current Employment	
Please complete the following information regarding your current or most recent employment.  The University may seek evidence of salary prior to appointment	
	
	Present Wage / Salary		_____________________	
	Period of Notice Required		_____________________	

Relevant Information	

Please demonstrate, on this page only, (by providing clear and unambiguous statement) how your qualifications, skills and experience meet the essential and, if appropriate, desirable criteria which are outlined in the Job Details.  In particular, you should clearly demonstrate how you meet the criteria marked with an asterisk.

	

References	

Please give the name and contact details of three persons, not relatives, both professional and personal, who may be contacted for references in support of your application.  One of these persons should be your most recent/present employer or course tutor/teacher if currently a student.	
REFEREE 1	
	Relationship to Referee (e.g. Manager)		     	
	Referee Title		     	
	Referee Forename		     	
	Referee Surname		     	
	Address Line 1		     	
	Address Line  2		     	
	Address Line  3		     	
	Postcode		     	
	Country		     		
	Referee e-mail address		     	
	Referee Telephone Number		     	
	Do we have permission to contact this		     	
	referee prior to interview?		     	
REFEREE 2		     	
	Relationship to Referee (e.g. Manager)		
	Referee 2 Title		     	
	Referee 2 Forename		     	
	Referee 2 Surname		     	
	Referee 2 Address Line 1		     	
	 Referee 2 Address Line 2		     	
	Referee 2 Address Line 3		     	
	Referee 2 Postcode		     	
	Referee 2 Country		     	
	Referee 2 e-mail address		     		
	Referee 2 Telephone Number		     	
	Do we have permission to contact this		     	
	referee prior to interview?		     	
REFEREE 3		     	
Relationship to Referee (e.g. Manager)		     	
	Referee 3 Title		
	Referee 3 Forename		     	
	Referee 3 Surname		     	
	Referee 3 Address Line 1		     	
	Referee 3 Address Line 2		     	
	Referee 3 Address Line 3		     	
	Referee 3 Postcode		     	
	Referee 3 Country		     	
	Referee 3 e-mail address		     	
	Referee 3 Telephone Number		     	
	Do we have permission to contact this		     	
	referee prior to interview?		     	

Other Information	

If your referees knew you be a different surname, please specify below:	
	
	Previous surname		_______________________________

Confidential Disclosure of Criminal Convictions	

Information about criminal convictions is requested to assist the selection process.

Below you are required to declare any previous criminal convictions.  This information will be treated in a confidential manner and will be considered as part of the shortlisting for the position

Failure to provide correct information may affect your application.  If an applicant is found to have withheld information about criminal convictions it may lead to dismissal.

Do not include those that would be considered 'spent' under the terms of the Rehabilitation of Offenders Order (NI) 1978

DATE
	
CONVICTION	
TYPE OF SENTENCE	
     

	     	     	
     

	     	     	
     

	     	     	

Statement of Disclosure	

We would encourage you to provide a statement of disclosure below providing any further information you feel may be relevant, such as the particular circumstances leading to the offence and why an employer should disregard the conviction.

	

Other Information	

	
                                             Date of Birth	
  _________________________
	
	National Insurance Number		________________________	

To enable the University to determine your Right to Work status, please state your nationality below:
	
	Nationality		________________________	

In accordance with the University’s equal opportunities policy the University would like to ensure that candidates, regardless of disability, can participate fully in the selection process.  If you consider yourself to have, or to have had a disability and require an specific arrangements to be put in place should you be invited for interview, please specify an such arrangements below:
	
	Specific Arrangements		_________________________

Declaration
I certify that, to the best of my knowledge, the information which I have given is true and complete.  I accept that, if I have supplied any false statements or have withheld any relevant information, any offer of employment can be withdrawn or an accepted appointment can be cancelled.  In addition to the referees quoted, I understand that the University reserves the right to make such further enquiries on my candidature as it deems appropriate including any unspent civil or criminal convictions.

Signature:_________________________________                                          Date:_________________________