Recruitment Information Dormer House School Recruitment Information High Street Moreton-in-Marsh Glos GL56 0AD 01608 650758 Application for appointment as Title (Mr. / Mrs. / Miss / Ms.) Surname First names All names used previously Address Postcode Telephone numbers Email address Previous address if less than 3 years at present address Educational Establishments From To Qualification and Grades Details of previous paid and unpaid work from the most recent: Job Title and Employer Reason for Leaving Final Salary Grade

Details of any breaks in employment Details of sickness absence in last 2 years, including number of days Two referees are required to support your application, one must be your current employer or if unemployed, your last employer and one must be personal but not a relative. Name and company Post Relationship to applicant Address, email and telephone no. Do you have any criminal convictions spent, unspent or pending? Yes No Do you need a work permit to work in the UK? For proof of identity and the Criminal Records Bureau check please bring your NI number, passport, driving licence and a recent utility bill to interview. For proof of qualifications please bring any relevant certificates to interview. I confirm that I am physically and mentally fit and able to carry out the tasks required of me within the remit of the job description. I have completed the medical declaration form. I certify that, to the best of my belief, the information I have provided is true and I understand that any false information or failure to disclose criminal convictions will result, in the event of employment, in disciplinary investigation and is likely to result in dismissal. Signature Date I hereby give my consent for personal information (including recruitment monitoring data) provided as part of this application to be held on computer or other relevant filing systems and to be shared with other accredited organisations or agencies in accordance with the Data Protection Act 1998. Dormer House School: Safer Recruitment: Application Form