Application form

Criminal Record Declaration

All applicants must complete this form in full and return it with their application form.
Title *

Mr Mrs Miss
Full Name *

First Name Middle Name Last Name
If any circumstances change which would affect your response to this question, you must inform us of the details without unnecessary delay.

Please answer the following questions:
1) Have you ever been convicted by the courts or cautioned, reprimanded or given a final warning by the police? Please give details of offences, penalties and dates in the table below.* (Note that the post you have applied for is exempted under the Rehabilitation of Offenders Act (Exceptions Order) 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need to be disclosed. * *

Yes (Please provide details) No (Proceed to Q2)
1a) Date / Year and Details * *
2) Have you ever been disqualified from work with children or vulnerable adults or subject to any other sanctions imposed by a regulatory body? * *

Yes (Please provide details) No (Proceed to Q3)
2a) Date / Year and Details * *
3) Are you registered with the Disclosure and Barring Service (DBS) Update Service *

Yes No
Please sign the following declaration. Failure to complete this declaration will result in your application being withdrawn.
I confirm that the information I have given on this form is correct and complete and I understand that any false information could result in my application being rejected or, if appointed, in my dismissal from this role. I understand that any offer of a role made to me will be subject to a further check with the Disclosure and Barring Service (previously Criminal Records Bureau) and I hereby give my consent to carry out the relevant DBS status checks where applicable in line with the DBS Code of Practice. I declare that I am not currently on the DBS Barred List and that I will provide notification notify if I do become barred in future. *

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Application Form

Criminal Record Declaration