IMPORTANT – Before filling in this form, please read the additional information for applicants carefully.

Please complete in BLACK ink or TYPE. CVs will not be considered.

YOU CAN ALSO APPLY ONLINE AT www.derbyshire.gov.uk

JOB DETAILS
Closing Date:

PERSONAL DETAILS

Title Surname First names

Previous names Preferred first name

(if any)
Address

Telephone Day

Evening

Mobile Postcode

Email If an email address is provided this will be used as the method of communication

PRESENT OR MOST RECENT EMPLOYER

Employer and address Job title

Annual salary or full time
Start date
equivalent

Notice required if working

Reason for leaving and

date (if applicable)

Brief details of main duties and responsibilities

Page 1 of 7 RESTRICTED (once completed)

PREVIOUS EMPLOYMENT

Please give details of all previous jobs since leaving full time education. Full details should be given for any period not
accounted for by full time employment, education or training (e.g. unemployment, voluntary work, raising a family, part
time work).
Employer and Dates
Job title and main duties Reason for leaving
address from to

MEMBERSHIP OF PROFESSIONAL BODIES/ASSOCIATIONS

Please give details of membership of professional or technical bodies/associations. This section will not be relevant
for some jobs.
Professional registration
Name of professional body Membership level Date joined
number/reference

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EDUCATION

Please give details of your education and qualifications.

Qualification(s) or Dates
Establishment attended Course title/subject
outcome from to

PROFESSIONAL AND VOCATIONAL TRAINING

Please give details of any relevant training. This section will not be relevant to some jobs
Qualification(s) or Dates
Establishment attended Course
outcome from to

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SUITABILITY FOR JOB

Please give further details about why you are suitable for the post, evidencing your previous experience, skills,
abilities and knowledge as related to the requirements detailed in the job and person profile. Please continue on a
separate sheet if necessary.

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REFERENCES
Please give the details of two people we may contact for references. Written references will be needed for any candidate who is
successful at interview. Please ensure your referees are aware of this, and are happy to provide this information. Referees will
be asked for detailed information including disciplinary issues and sickness absence where appropriate.
Name of your first referee Name of your second referee

Their job title Their job title

Their relationship to you e.g. line manager but, when applying for posts
Their relationship to you e.g. line manager
based in schools, this should be the headteacher or senior manager

Organisation and address Organisation and address

Postcode Postcode
Email Email
Telephone Telephone

Can we contact your present employer for a reference before an offer of employment is made? Yes No
For all posts where you are employed directly by the school’s governing body or if you are applying for a post as a
teaching assistant in a Council service references will be taken up prior to interview; if you do not give your permission
for this to be done you should contact the head of the establishment or recruiting manager to discuss. Details of your
sickness absences will only be requested if you are the successful candidate. For these posts you must give your
current employer or most recent employer and, where possible, another professional referee. Referees cannot be
family or people writing solely in the capacity of a friend.

ASSOCIATION WITH A COUNTY COUNCILLOR OR EMPLOYEE OF DERBYSHIRE COUNTY COUNCIL

Do you have a close association with a county councillor or employee of Yes No

Derbyshire County Council?
If you have answered yes, you are required to declare the name and relationship involved.

Their name Their job Their department Your relationship

Please note Any applicant who directly or indirectly seeks the support of any councillor or officer for any appointment
with the council will be disqualified.

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DISCLOSURE OF CRIMINAL RECORDS
If you are the successful candidate we will ask you to disclose any criminal convictions, warnings, reprimands,
cautions, or other orders, pending prosecutions, or criminal investigations. We will only take them into account if
we consider them relevant to the job for which you have applied. You are not required to disclose offences which
are spent under the Rehabilitation of Offenders Act 1974, unless the post for which you have applied is exempt under
the Act. For these exempt jobs both spent and unspent offences must be disclosed, unless they are “protected” as
defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales)
Order 2013. If the vacancy for which you are applying requires such a disclosure, this will be stated clearly on the
advertisement and the supporting details you will have received with this form. For these posts an offer of
appointment will be subject to satisfactory Disclosure & Barring Service clearance. Any information disclosed will be
treated in the strictest confidence.

Have you lived or worked abroad in any one country for 6 months or longer at any time since the age of 18?

Yes No

If Yes, please give dates and countries

DECLARATION
I declare that the information on this form is true and accurate. I understand that providing misleading or false
information will disqualify me from the appointment or may lead to me being dismissed if appointed to the post.

Privacy Notice - The information contained in this form, and any other information received on or on behalf of the
council relating to your application will be processed by the council as part of its legitimate interest in administering the
recruitment process. Your personal details will be held only for this purpose and will be shared with our third party
recruitment system provider, Giant Precision. Your data will only be accessed by employees in the legitimate
performance of their duties and will be held in accordance with the HR retention schedule and in accordance with the
Data Protection Act. [2018] and the General Data Protection Regulation. For details of the Council’s recruitment
system Privacy Notice please see our website.

Signature Date

Please advise us of any other information relevant to the recruitment process so we can ensure every attempt is
made to meet your needs. This could include dates when you are not available for interview or any special
requirements you may have such as necessary equipment and/or resources to enable you to attend an interview.

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EQUAL OPPORTUNITIES MONITORING FORM
The council is committed to its equality and diversity policy. We want to do all we can to prevent discrimination in any form
and you can help us in this by completing the information below. The information given on this sheet will not be used to
make decisions about who is recruited. The form will not be seen by the shortlisting/interview panel (but if you are disabled
this fact will be passed on to the recruiting manager so that we can meet our obligations as a Disability Confident
Employer). The form will be used to improve equality in recruitment and overall service delivery. Your help filling in this form
is greatly appreciated. Thank you.
JOB REFERENCE No. DCC / /

DATE OF BIRTH DD MM YYYY

RACIAL OR ETHNIC ORIGINS

White British WB Other mixed background MO Black Caribbean BC

White Irish WI Indian AI Black African BA
White other WO Pakistani AP Other black background BO
White & Black Caribbean MC Bangladeshi AB Chinese OC
White & Black African MB Other Asian background OA Gypsy or Irish Traveller OG
White & Asian MA Arab AR Any other OT

DISABILITY

Are you disabled? Yes No

Derbyshire County Council welcomes applications from disabled people and undertakes to offer every appropriate
support to enable them to gain and retain employment.

GENDER

Male Female

RELIGION / BELIEF – please tick only one box

Buddhist Jewish None

Christian (all denominations) Muslim Other religion or belief
Hindu Sikh Prefer not to say

SEXUAL ORIENTATION – please tick only one box

Bisexual Lesbian or gay woman Gay man
Heterosexual Other Prefer not to say

HOW DID YOU FIND OUT ABOUT THIS JOB?

e.g. council website, newspaper (please tell us which), Job Centre etc.

EMPLOYMENT
Do you work for the Derbyshire County Council at the moment? Yes No

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