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					Tel: 023 8072 1234                                                     Bradbury Centre
Fax: 023 8051 3473                                                  300 Aldermoor Road
www.roseroad.org.uk                                                        Southampton
                                                                            SO16 5NA


                          APPLICATION FOR TRUSTEE ROLE

                  Your application will be judged solely on its merits.
   Please complete clearly in black/blue ink or typescript. Please continue on separate
                            sheets throughout if necessary.

PERSONAL DETAILS:

Title (Ms, Miss, Mrs, Mr etc):                     Surname:

Forenames:

Address:

                                                   Postcode:
Contact Details:
Home:                                        Mobile:
                                              What is the best time to contact you?
Email:

We encourage applications from people who have a disability, so we would like to know if
you are registered disabled or have a disability: YES / NO

If yes is there anything we need to know about your disability in order to offer you a fair
selection interview? For example, do you have any specific access requirements?


EMPLOYMENT & QUALIFICATIONS RELEVANT TO ROLE
EMPLOYMENT & QUALIFICATIONS RELEVANT TO ROLE Cont…




WHY YOU’RE APPLYING (Please use additional sheets if necessary).
What experience and expertise would you bring to the Board of Trustees?
REFERENCES
Please give all the following details for two referees. Referees should not be a family
member.
Name:                                            Name:
Job Title:                                       Job Title:
Organisation:                                    Organisation:
Address:                                         Address:

Postcode:                                     Postcode:
Telephone:                                   Telephone:
Email:                                       Email:
Fax:                                         Fax:
Relationship:                                 Relationship:
May we approach prior to interview?
Referee 1:           YES / NO                 Referee 2:              YES / NO
DECLARATION

Do you know of any reason which would prevent you becoming a company director or a
charity trustee, such as undischarged bankruptcy, unspent conviction for deception or
dishonesty or previous removal as a charity trustee on these grounds?

Yes/No

The role of trustee of a children’s charity is classed as an exception to the Rehabilitation
of Offenders Act 1974 and previous convictions are not considered “spent”. Do you
have any criminal convictions, cautions or warnings, including any prosecutions pending?

Yes/No

 The Rose Road Association reserves the right to verify with the Home Office and
           ID documents produced during the recruitment process.
Signed:                                Date:

				
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