Please list below a complete record of other employments and include, if you wish, any voluntary activities either paid or unpaid. These should be in date order, starting with the most recent. Please explain any gaps in employment.

(Continue on separate sheet if required)

As defined by the Rehabilitation of Offenders Act 1974 and subsequent regulations, under section 4.2 you do not need to declare convictions which are 'spent'.

However, by virtue of the Rehabilitation of Offenders (Exceptions/Amendments) Order 1986 those provisions do not apply if you are applying for a job supervising, caring for or otherwise connected with people from the following list, you must always declare any convictions and/or cautions for criminal offences, even where they are'spent'.  For these purposes, this includes working with children, young and older people, those who are dependent on alcohol or drugs, and those with mental or physical disabilities, illness,injury or deformity, including people who are blind, deaf or without speech.

* Please note if you have any cautions orconvictions that you do not declare on this form then we will not be able tooffer you a position. Please list all cautions and convictions

PLEASE PROVIDE TWO PROFESSIONAL REFERENCES, ONE MUST BE YOUR CURRENT/LAST EMPLOYER

The information that I have provided is to the best of my knowledge. I understand that giving false information or omitting relevant information could disqualify my application and, if I am appointed,could lead to my dismissal.

We regularly review and improve our recruitment process; therefore we ask that you complete the following form to assist us with such improvements.

Information you provide in this form will not be used in selecting or not selecting you for an employment position, and is used to monitor our equal opportunities policy. This information is confidential and you will not be identified by any information you provide in this form. Completed forms will be detached from your application upon receipt and will not be held in employment files. This form is not part of your application.

Ethnic Origin (The following categories are recommended by the Commission for Racial Equality.  If you feel the choices do not provide a suitable option, please write down how you would describe your ethnic origin)