Application Form

1. Title* MissMrsMsMr
2. Surname*
3. Forename*
4. Address*
5. City*
6. State / Province / Region
7. Postcode*
8. Date of birth*
9. Place of birth*
10. Phone Number*
11. Email*
12. Do you have the right to work in the UK?* yesno
13. Do you have a current CRB or are you registered on the updated system?* (please provide your current certificate number and date of issue) yesno
14. Please tell us where you heard about Superior Sitters ---ReferralSocial MediaSearch EngineGoogle MapNextdoorLibraryNewspaperLeafletOther
15. Message

Referee No1

1. Name*
2. Job title*
3. Address*
4. Telephone no.*
5. Email address*
6. Can we approach this referee prior to interview?* yesno

Referee No2

1. Name*
2. Job title*
3. Address*
4. Telephone no.*
5. Email address*
6. Can we approach this referee prior to interview?* yesno

1. Date From*
2. Date To*
3. Name & Address of Institute/Training body*
4. Results/Certificate Qualifications gained*

PLEASE PROVIDE DETAILS OF YOUR EMPLOYMENT HISTORY (starting with your current
or recent employment first)

1. Dates From*
2. Dates To*
3. NAME AND ADDRESS OF ORGANISATION*
4. Telephone no.*
5. Job/role and brief description of duties*
6. Reasons for leaving*

As the role that you are applying for involves working with children, please make sure you
provide all information regarding any spent and unspent convictions including dates.

Please answer the following questions

1. Have you been known by any other name or changed your name in the last year?* yesno
2. Do you have any criminal records to declare?* yesno
3. If yes, please provide details including dates
4. Are there any current criminal proceedings against you?* yesno
5. If yes, please provide details
6. Is there anything else you would like to declare?* yesno
7. Have you been the subject of any child protection investigation, including any allegations relating to child abuse, bullying, intimidation, professional malpractice or misconduct?* yesno
8. If yes, please statement

I have completed this application form accurately and truthfully, I have not withheld information that may be relevant to my application. Any job offers or booking with Superior Sitters will be subject to the information provided on this application form being correct. Any false information provided on this application form shall lead to disqualification to any job offer or if false information is discovered after any job offer this will lead to termination of contract with Superior Sitters. It is a breach of contract to accept bookings from parents introduced to you by SuperiorSitters and you will be taken off our booking system if we have reason to believe that you have breached your contract agreement with SuperiorSitters.

(AS THIS IS A SELF EMPLOYED EMPLOYMENT YOU ARE THEREFORE RESPONSIBLE TO DECLARE YOUR EARNING TO HMRC)

1. Date*
2. Sign*
3. Name*

Information provided in this section is solemnly to monitor recruitment effectively, any information provided, collected regarding your gender, race ethnicity and any disability will be treated confidential and will not be used as part of the recruitment process.

1. WHITE ---BritishIrishEuropeanOther

1. MIXED ---White & Black CaribbeanWhite & Black AfricanWhite & AsianAny other mixed

1. BLACK/BLACK BRITISH ---AfricanCaribbeanOther

1. ASIAN/ASIAN BRITISH ---IndianPakistaniBangladeshiOther

1. OTHER ---ChineseVietnameseFilipinoOther

1. Do you consider yourself disabled? yesno