Thank you for applying for a position with Newport City Council

The information requested in this form is important in assessing your application. Please complete it accurately and in full. A CV on its own will not be accepted as an application but can be included to supplement the application form. To help reduce our costs, we do not automatically acknowledge receipt of application forms or write to applicants not selected for interview. If you do not hear anything within 6 weeks of the closing date, please assume that your application has been unsuccessful.

PRIVATE AND CONFIDENTIAL

Please complete in black ink and refer to application guidance for additional information
Section 1 - Post Details
Job title of post applied for: Unique reference number (not applicable if downloaded from internet): Reference number of vacancy for which you are applying: Please indicate where you saw the post advertised below: Press/Publication Please specify: Internet- Please specify: If other, please specify:

Forename( s)

Job centre Plus Word of mouth

Section 2 - Personal Details

Surname Address Post Code Home Telephone Business Telephone Mobile Telephone E-mail Address National Insurance Number

(Code ) (Code )

(No.) (No).

Extensio n

Do you need a work permit to work in the UK?

Yes

No

The Council operates under the Positive about Disabled People Scheme and applications from people with disabilities are welcomed by the Council. This scheme guarantees an interview to people with disabilities if they satisfy the essential criteria for the post. Declaration I have a disability & wish to be given a guaranteed interview under the Councils commitment to the Positive about Disabled People (please check box)

TrainingSection 3 - Education &

Proof of qualifications may be required at interview

Date to & from Month/Year Schools, Colleges, Training Centres attended - including part time Qualifications gained or pending (state subject & level) Grade

Section 4 Present/most recent employment

Name and address of present or most recent employer:

Dates of employment From (month/year):

To (month/year):

Job Title and brief description of duties/responsibilities:

Reason for wanting to leave Salary Job Title of immediate supervisor

How many employees do you supervise? Other financial benefits Period of notice

Professional Membership employmentSection 5 - Previous

Please enter in reverse date order and include any training placements, temporary unpaid or voluntary work experience
Dates to & from Month/Year Employers Name & Address Job Title & Salary Brief Description of Duties Reason for leaving

Membership of Professional Bodies

Body Grade of Membership Whether by exam Date

Section 6 - Other relevant

The information you provide in this section is important in assessing your application. Please use the space to: state your reasons for applying for the post; relate your skills, experience, and personal qualities and training you have received to the requirements of the job which are contained in the job description and job requirement form. For advice on completing this section please read the document Applying for a job in Newport on www.newport.gov.uk/jobs

information and experience Are you related to any Member or employee of Newport City Council? If so, please state name and relationship. Have you been convicted of a criminal offence? Section 7 Miscellaneous

YES

NO

YES NO

If yes, please give details including dates except spent convictions under the Rehabilitation of Offenders Act

Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 & Police Act 1997 If the Job Description has indicated that the post for which you are applying will be subject to a Criminal Records Bureau Disclosure, the Authority will require you to reveal any criminal convictions, bind-over orders or cautions, including those which would normally be regarded as spent. Please give details

Information regarding CRB Disclosures is attached.

(continued)Section 7 Miscellaneous

Do you hold a full valid driving licence? If it is a non UK licence, please specify country of issue Do you hold a full valid HGV Licence? Do you hold a full valid PSV Licence?

YES YES YES YES

NO NO NO NO

If you have any driving endorsements and/or penalty points please detail:

Please give the names of two persons to whom reference may be made in respect of your application. The first should be from your last employer (or Head Teacher if a school leaver). The Council requires references to be supplied from all previous employers over the last 3 years. Please supply the names of additional references on a separate sheet. Referees are only contacted if candidates are to be interviewed. The Council reserves the right to contact any previous employer. Name Address

Section 8 - References

Position

Telephone E-mail Number If you do not wish this referee to be contacted until a provisional offer of employment is made, please tick this box

Name Address Telephone Number

Position

E-mail

If you do not wish this referee to be contacted until a provisional offer of employment is made, please tick this box Section 9 - Declaration The information you have provided on this form is subject to the Data Protection Act 1998. It will be held by the Council for recruitment purposes. If you are appointed this information will be retained for the duration of your employment with the Council. If you are not appointed your information will be kept for a period of 12 months following the appointment decision after which it will be destroyed. I am happy for Newport City Council to disclose my name, date of birth and national insurance number to Jobcentre Plus.

YES

NO

Declaration I declare that the information given in this application is complete and true, that I have not canvassed (either directly or indirectly) any Member or Senior Officer of Newport City Council and will not do so.

Signed

Date

Application Checklist

Please ensure that you have referred to the guidance notes and complete and return the following: Have you identified which vacancy (Job Title & Unique Reference/Job Reference Number) you are applying for on the application form? Have you completed and included the equal opportunities form? Please ensure it includes the Job Title and Unique Reference/Job Reference Number (You may wish to place this in a separate envelope) Have you provided details of at least two referees that cover your last three years of employment? Have you read the declaration above and dated your application form? If you have chosen to include additional information, have you attached this to your application form?

Save your completed form to your computer and then submit your application form on-line by clicking here and follow the links to submit your application online.

PLEASE LEAVE THIS PAGE BLANK AND CONTINUE TO THE EQUAL OPPORTUNTIES FORM BELOW

PRIVATE & CONFIDENTIAL

Equal Opportunities Monitoring Form

Data Protection Act 1998 The information you provide on this form will be stored either on computer or in the form of manual records. It will be used by the Council solely to monitor the implementation of its Equal Opportunities and related employment policies. It will not be used for any other purposes or disclosed to any other organisations except in pursuance of our statutory obligations. Could you please complete this form and return it with your application form. It will be separated from the Application Form on receipt. Officers involved in the selection process do not at any stage have access to the data collected. However, should you have any concerns, please insert the Monitoring Form into an envelope, write the Job Reference Number on the outside of the envelope and return with the application form. We would assure you that this envelope would not be opened until the conclusion of the recruitment process. Unique reference number (not applicable if downloaded from internet) Reference number of vacancy for which you are applying Job title of post applied for Please tick appropriate boxes below Corporat e Services My gender is (please tick Male appropriate box) How would you describe your ethnic origin Service Groupings Environment & the Economy Female White British Irish Any other white background Please specify below: Mixed White & Black Caribbean White & Black African White & Asian Any other mixed background Please specify below: Lifelong Learning & Leisure Social Services

Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background Please specify below: Black or Black British Caribbean African Any other Black background Please specify below: Chinese or Other ethnic group Chinese Gypsy/traveller Any other ethnic group Please specify below:

(These categories are those used in the 2001 census and are recommended for use by the Commission for Racial Equality) Age 162030405065 60-64 s 19 29 39 49 59 + Are you a disabled person?

YES

NO

The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has a substantial and long-term adverse effect on a persons ability to carry out normal day to day activities.