Join Us - Help to Health

General details

First names

Surname

Home address

Previous address 1

Previous address if outside County Durham

Previous address 2

Previous address if outside County Durham.

Telephone number

Alternate telephone number

Email address

Date of birth

Please use dd/mm/yyyy format.

Do you hold a full current Driving Licence?

Car owner/driver?

Training and Qualifications

If applicable.

Dates of courses and results

Other relevant information

References

Please give the name, address and occupation of TWO referees.

Referee #1 Name

Referee #1 Occupation

Referee #1 Telephone

Referee #1 Address

Referee #2 Name

Referee #2 Occupation

Referee #2 Telephone

Referee #2 Address

Court Offences

Have you been convicted in any court of any offence?

If yes, please specify

Under the Rehabilitation of Offences Act 1978 (Exceptions) Order, 1975 applicants are required to disclose information concerning convictions including those which for other purposes are regarded as “spent” under the Act. If you take up an appointment with Supportive SRC Ltd and you have failed to disclose such information this could result in dismissal or disciplinary action. Any information divulged will be treated in strict confidence and will be considered only in relation to applicants for posts subject to the provision of the above order.

I give permission for Supportive SRC Ltd to carry out a Police Check

Declaration

Are you related to any Committee Member(s) or Senior Officers of Supportive SRC Ltd?

If yes, please give name and relationship.

Failure to disclose such a relationship shall, if the appointing Committee so declare, disqualify you from the appointment and if appointed shall render you liable for dismissal without notice.

Canvassing of Members of the Committee directly or indirectly for any appointment is prohibited and shall, if the appointing Committee so declare, disqualify the Candidate for that appointment.

Date

Signed

Type name or initials.

Supportive SRC Ltd is an Equal Opportunities employer and welcomes all applications irrespective of race, disability, religion, sexual orientation, marital status, political belief and age.

E-Mail

Volunteer Application Form