APPLICATION TO BECOME A POTENTIAL BOARD MEMBER
OF WM HOUSING GROUP OR WEST MERCIA HOMES OR WHITEFRIARS
Please be aware that this form will be circulated to members of the selection and interview
panel as part of the application process and by its completion you agree to this circulation
1. PERSONAL DETAILS
Your Full Name:
2. PLEASE SET OUT YOUR REASONS FOR WISHING TO BECOME A
BOARD MEMBER (continue on an additional sheet if necessary)
3. PLEASE DESCRIBE THE SKILLS, EXPERIENCE AND OTHER
CONTRIBUTIONS YOU WOULD BRING TO THE BOARD
(please read our Overview of Board Members’ Role and Competencies when
completing this section)(continue on an additional sheet if necessary)
4. EDUCATIONAL, PROFESSIONAL AND BUSINESS BACKGROUND
Please complete the following:
Are you currently in employment? Yes/ No (please delete as appropriate)
Is a copy of your CV attached? Yes/ No (please delete as appropriate)
If your CV is not attached, what is or was your educational,
professional or business background/experience (paid or voluntary)?
Dates Position Name and Location of
Do you have a professional qualification? If so, please state:
Which Board would you prefer to join?
(WM Housing Group; West Mercia Homes; Whitefriars)
Where did you hear about this position?
Board member application contact and declaration of
1. Your contact details:
First Name(s): Surname:
Title: Date of Birth:
Post Code: Telephone No:
2. DECLARATION OF POTENTIAL INTERESTS:
Please cross the relevant box (Yes or No) below as applicable:
Closely Connected referred to below includes a spouse or partner; close relative including
parent, child, brother, sister, grandparent, uncle, nephew or niece and includes step
children, relationships by half blood and similar relations by marriage or partnership; any
company or business controlled by you or persons closely connected to you or in which
such persons have a substantial interest; close friend with whom a social relationship has
been established over time
Group referred to below includes WM Housing Group Limited, West Mercia Homes
Limited, Whitefriars Housing Group Limited, Optima Community Association, Nexus
(Midlands) Housing Association (2005) Limited, Kemble Housing Limited
1 Do you,or any person Closely Connected to you, hold a tenancy,
lease or licence of any property owned or managed by our Group or *
use any of our other services?
2 As far as you are aware, are you or any person Closely Connected to
you, related to or have any personal relationship with any of our *
Group’s Board Members or employees?
3 Are you a current or former member of any housing association,
voluntary body or co-operative?
4 Are you a member of any community or residents group? *
5 Do you hold any positions of public responsibility (eg school
6 Have you, or as far as you are aware any person Closely Connected
to you, sold or leased any property or land to any member of our *
7 Do you, or as far as you are aware any person Closely Connected to
you, have any financial interests relating to our Group’s business?
8 Are you, or as far as you are aware any person Closely Connected to
you, an officer (eg director), partner, sole trader, employee, owner or
controller or directly concerned in the management of a *
company/business or other organisation which has a contractual or
other relationship with our Group?
9 Are you, or as far as you are aware any person Closely Connected to
you, an owner or controller of more than 2% of a publicly quoted *
company or more than 10% of any other company?
10 Are you, or as far as you are aware any person Closely Connected to
you, an official, officer or elected member of any statutory body
(including Local Authorities) or been a former Member in the last four
years or an officer of a company controlled by a Local Authority?
11 Are you subject to any court order or written professional opinion
that would prevent you from personally exercising any powers eg due *
to mental health reasons?
12 Are you bankrupt or have you made a voluntary arrangement,
agreement or composition with your creditors in satisfaction of any *
13 Have you been a director or officer of a company or other
organisation which has gone into insolvent liquidation or similar *
14 Are you or have you been disqualified from acting as a director,
trustee, board member or other officer of any organisation for any *
15 Do you agree to have a criminal records bureau check? *
If you completed any of the boxes marked * to any of the above questions,
please include details in the space provided:
Please list all businesses/organisations/bodies (including businesses trading
for profit and not for profit eg charitable organisations) in which you, or as far
as you are aware any person Closely Connected to you, has an interest eg as
a director (executive or non executive), board member, an officer, a member of
a firm, partner, sole trader, employee, shareholder or are an owner or directly
concerned in the management of that business
REHABILITATION OF OFFENDERS ACT 1974
The Exception Order 1995 requires disclosure of “spent” convictions if you
are applying for positions within finance, care or with young people under the
age of 18. This post is covered due to the financial responsibilities it carries.
If you inadvertently disclose a conviction, which is regarded as “spent”, it will
Have you ever been convicted of a criminal offence?
If yes, please give details on a separate sheet.
ASYLUM AND IMMIGRATION ACT 1996
Under the terms of the Asylum and Immigration Act 1996 we will need to see a
document which confirms your entitlement to take up remunerated posts in
the UK before you take up office. It would also be helpful if you could confirm
entitlement at this stage.
I confirm that I am entitled to take up the post in the UK
Please give the name, address and contact number or email address of two
referees, one of whom should be your present or immediate past employer (if
applicable). References will be taken up for shortlisted candidates only.
I declare that, to the best of my knowledge and belief, the information I have
given in my application is true and accurate. I understand that any offer of
office is conditional upon the accuracy of this information. I understand that
any false or misleading information, as well as withholding relevant
information, may lead to my application being disqualified, or the withdrawal
of an offer, or if I have been appointed, to my dismissal. I also declare that I
have read and understood the Overview of Board Members’ Role and
Competencies contained in the application pack and I would be prepared to
accept these obligations.
DATA PROTECTION ACT 1998
By signing this form you give the Group permission to collect, retain and
process information about you. This information will only be used so that we
can monitor our compliance with the law and best practice in areas such as
equality of opportunity, non-discrimination and remuneration administration
EQUALITY AND DIVERSITY MONITORING
To monitor our activities, it is necessary to collect information from applicants on
key characteristics that relate to equality and diversity. The information collected
will be used in relation to the collation of statistics and to monitor the operation of
our equality and diversity statement. This sheet will be treated as confidential and
will be separated from your application before short listing.
Please complete the appropriate box/section
1. Your Gender :
2. Your Date of Birth :
3. Your Ethnic Origin and Disabilities:
Ethnic Origin (please cross against the appropriate box)
White: British Asian or Asian British: Indian
White: Irish Asian or Asian British: Pakistani
White: Other Asian or Asian British:
Mixed: White & Black Asian or Asian British: Other
Mixed: White & Black African Black or Black British: Caribbean
Mixed: White & Asian Black or Black British: African
Mixed: Other Black or Black British: Other
Chinese Other ethnic group
Do you have any disabilities? Yes/No
Do you need us to make any special arrangements to help you attend an
interview if requested?
This information will be protected in line with the Data Protection Act 1998 by the
Group as detailed in the statement above. Please sign the declaration below to
consent to your personal sensitive data being used and held on our manual and
Please return the completed application form to:
Group Company Secretary
WM Housing Group
Barnsley Hall Road
Email : email@example.com