Application for Employment - Confidential Information Step 1 of 8 12% Position Applied for* Personal DetailsYour Name* MrMrsMissMsDrProf.Rev. Title Surname Forename(s) Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone numbers:Home:* Work:* (only if we may telephone you there)Mobile:* Email:* ReferencesPlease give the names and contact details of two referees whom we can contact to provide information in support of your application. One of these should be your current manager: if you are not in employment, please supply the name of your most recent employer or an academic reference (e.g. tutor or teacher). As such, Severn Arts implements a Safer Recruitment Policy. This requires references to be taken up once applicants have been shortlisted for interview. Please indicate here if you have any concerns about references being taken up at shortlisting stage. Please ensure that your referees are aware of this application, and also, if you are providing us with their email address, that you obtain your referee's permission.First ReferenceName* MrMrsMissMsDrProf.Rev. Title Surname Forename(s) Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Position held in relation to applicant* Referees may be contacted prior to offer being made*YesNoSecond ReferenceName* MrMrsMissMsDrProf.Rev. Title Surname Forename(s) Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Position held in relation to applicant* Referees may be contacted prior to offer being made*YesNo REHABILITATION OF OFFENDERS ACT 1974Applications from ex-offenders are welcomed and will be considered on their merit. Convictions that are irrelevant to this job will not be taken into account. You are required to disclose any convictions, which are not 'spent' by virtue of the Rehabilitation of Offenders Act 1974.Have you ever been convicted of a criminal offence, which is not spent, as defined in the above Act?*YesNoDetails of Offence*If "Yes", please give details of date(s), offence(s) and sentence(s) passed. If "No", please write N/APlease also confirm that you are not listed on either of the following (as appropriate):* I confirm that I am not listed on the children's barred list. I confirm that I am not listed on the adults' barred list. I declare that I have no past convictions, cautions or bind-overs and no pending cases affecting why I might be considered unsuitable to work with children/vulnerable adults. The information you provide will be treated as confidential and will be considered only in relation to the job for which you are applying. Equal OpportunitiesWe aim to be an equal opportunities employer, and our policy is that job applicants and employees receive equal treatment regardless of sex, race, disability, sexual orientation, religion or belief, age, marital status or civil partnership, pregnancy/maternity or gender reassignment, where any of these cannot be shown to be a requirement of the job concerned. Recruitment, selection and promotion procedures will be monitored to ensure that individuals are selected, promoted and treated on the basis of their relevant merits and abilities. To assist us in monitoring the operation of our equal opportunity policy, and for no other reason, please answer the following questions. Sex*MaleFemalePrefer not to sayAge*16-18 YRS19-21 YRS22-35 YRS36-45 YRS46-64 YRS65 YRS AND OVERPrefer Not To SayDo you consider yourself to have a disability?*YesNoPrefer not to sayIf yes, please give brief details of the disability and any adjustments that would need to be made to enable you to carry out the duties listed for this post.Race*White BritishWhite Irish (Dual Heritage)White and Black Caribbean (Dual Heritage)White and Black African (Dual Heritage)White and Asian (Dual Heritage)White and Black Carribean (Dual Heritage)White and Black African (Dual Heritage)Indian (Asian or British Asian)Pakistani (Asian or British Pakistani)Bangladeshi (Asian or British Bangladeshi)Black Carribean (or British Black)Black African (or British African)ChineseAny other White background (please state below)Any other Asian background (please state below)Any other Mixed background (please state below)Any other Ethnic group (please state below)Prefer Not To SayPlease State Other Background Here:* Sexual Orientation*Lesbian/GayBisexualHeterosexualPrefer Not To SayReligion*Christian (any denomination)BuddhistHinduJewishMuslimSikhNo ReligionAny Other ReligionPrefer Not To SayPlease State Other Religion Here:* Positions HeldFirst Position - Date Started/Left:* Name and address of employer:* Please give a brief description of duties:* Reason for leaving:* Second Position - Date Started/Left: Name and address of employer:* Please give a brief description of duties:* Reason for leaving:* EducationLast School:* College:* University:* Qualifications Gained (Subjects/Grades):* Training / Professional MembershipIt is our policy to verify professional membership details of successful applicants, where these are a requirement of the role.Course/Organisation (with brief details after each line):Personal Statement*With reference to the person specification, please explain why you consider yourself to be a suitable candidate for this position, including examples of you relevant achievements, as well as what motivates you to apply. DATA PROTECTION STATEMENTInformation from this application may be processed for purposes permitted under the General Data Protection Regulation. Individuals have, on written request, the right of access to personal data held about them. Severn Arts treats personal data collected during the recruitment process in accordance with its Privacy Statement. Information about how your data is used and the basis for processing your data is provided in this privacy statement, available on the Severn Arts website.DECLARATIONI confirm that the above information is complete and correct and that any untrue or misleading information will give Severn Arts the right to terminate any employment offered. I understand that any offer of employment is subject to Severn Arts being satisfied with the result of a series of relevant checks including references, eligibility to work in the UK, criminal convictions, probationary period and a medical report (in line with the operation of the Equality Act 2010).If you have a disability, and there are any special arrangements which need to be made should you be short-listed for interview, please contact us to notify us of these. All information given is private and confidential.If you have a disability, and there are any special arrangements which need to be made should you be short-listed for interview, please contact us to notify us of these. All information given is private and confidential.Signed (full name):* Date:* MM slash DD slash YYYY