APPLICATION FORM Please read the guidance notes. You must not alter the design or layout of this form in any way. Post applied for Vacancy No. PERSONAL DETAILS Surname Date of Birth Telephone Numbers NI Number Home Work Do you consider yourself to have a disability? Please tell us about any reasonable adjustment you need to help you with your employment application, and Please tell us about any reasonable adjustment you need to help you do the job you are applying for? If you are applying for a post open to job share please indicate how you wish to work by ringing one of the following. FULL TIME ONLY Do you hold a UK driving licence for a car? CURRENT OR LAST EMPLOYMENT Employer’s name Employer’s address Position held JOB SHARE ONLY Yes / No EITHER If registered disabled, please give your registration number? Post Code First name(s) Address Directorate or Establishment Yes / No Date started Date finished Salary Other Benefits Brief description of duties, responsibilities etc ACTION FOR EQUALITY Northumberland County council aims to ensure that no job applicant or employee receives less favourable treatment than another on grounds of sex, race, colour, ethnic origin, religion, marital status, sexuality, disability, age (within the context of normal retirement age) or any other factor unrelated to the requirements of the job and which are not restricted by legislation. OTHER WORK EXPERIENCE - Please list most recent first From To Name and address of employer Position held Final salary EDUCATION, VOCATIONAL TRAINING AND QUALIFICATIONS - Please list most recent first From To Establishment Examinations, qualifications, grades and achievements FURTHER DETAILS IN SUPPORT OF YOUR APPLICATION LEISURE INTERESTS AND HOBBIES (you may wish to include positions of responsibility held) REFERENCES Give the names, addresses and telephone numbers of two referees. One must be your current or last employer. 1 Name Position Relationship Address 2 Name Position Relationship Address Telephone No. Permission to contact prior to interview Yes/No Telephone No. Permission to contact prior to interview Yes/No REHABILITATION OF OFFENDERS ACT 1974 A letter X in the vacancy number indicates that the post for which you are applying is exempt from the provisions of the Rehabilitation of Offenders Act 1974. In this case you must give details of any convictions, both spent and unspent, on a separate sheet. (A police check may be undertaken for certain types of employment). CANVASING If you are related to any Councillor, Senior Officer of Northumberland County Council, Head Teacher or School Governor of a Northumberland County Council school, please give details. CANVASSING WILL DISQUALIFY APPLICANTS REFERENCES I declare that the information given above is correct to the best of my knowledge. I understand that deliberately giving false or incomplete answers would disqualify me from consideration, or, in the event of my appointment, make me liable to dismissal. SIGNED………………………………………………………………………………………………DATE…………………… NB - If you are not notified in writing within six weeks of the closing date for applications, you may assume that you have not been selected for interview on this occasion.