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1 To fill this form in and save it electronically you will need Acrobat Reader 7 or above. Download the latest version from or contact your IT help desk. Application Declaration Form Statement of Interest Name: Please complete this Statement of Interest to show how you meet the internship criteria. You will also need to attach a copy of your CV and it to RisingHigh@suffolk.gov.uk or post it to the address below. Please note: no applications or statements, online or otherwise, will be accepted after 1pm on the closing date. Your statement should not be longer than 2 sides of A4 paper. It is important that you provide evidence of how you meet the criteria set out in the internship wheel. Include things you were responsible for and what you achieved. Use examples from paid or unpaid work or other activities you have undertaken that are relevant to the job you are applying for. Also include other information about why you want the job and anything else you wish to say. Please include headings linked to the internship criteria. Continue on next page if required of data therein and that this will comply with the Data Protection Act Page 1 of 5

2 Statement of Interest additional information of data therein and that this will comply with the Data Protection Act Page 2 of 5

3 To fill this form in and save it electronically you will need Acrobat Reader 7 or above. Download the latest version from or contact your IT help desk. Application Declaration Form If you are applying via a CV and/or Statement of Interest please read, complete and sign this declaration and attach it to your application. Please return completed applications to: CSD Resourcing Constantine House 5 Constantine Road Ipswich Suffolk IP1 2DH CRIMINAL CONVICTIONS Please give details of criminal convictions below. Unless stated otherwise you do not need to declare convictions which are spent, as defined by the Rehabilitation of Offenders Act 1974 and subsequent regulations. However, if you are applying for a job which has been identified as involving supervising, caring for or otherwise connected with children, young people or vulnerable adults, you must always declare all convictions, cautions and/or bindovers for criminal offences, even where they are spent as defined by the Rehabilitation of Offenders Act 1974 and subsequent regulations. You are also required to give details of any reprimands or warnings that you may have received. For certain posts a Disclosure and Barring Service (DBS) check will be required. If it is necessary you will be asked to sign a separate authorisation. Details of criminal convictions Please state NONE if appropriate and continue on a separate sheet if necessary: Are you, or have you ever been an employee of Suffolk County Council, Mid Suffolk District Council or Babergh District Council? Yes No DISABILITY* The provision for disability within Equalities legislation defines a person as disabled if they have a physical or mental impairment, which has a substantial and long term (i.e. has lasted or is expected to last at least 12 months) adverse effect on the person s ability to carry out normal day-to-day activities. Do you have a disability as defined above? Yes No If you have a disability, are there any arrangements which we can make for you if you are called for an interview and/or work based exercise? Yes No If Yes, please specify, (e.g. ground floor venue, sign language interpreter, audio tape etc.) We offer a guaranteed interview to all disabled candidates who meet the minimum essential criteria for a job vacancy. *For statistical purposes only not used as part of the selection process of data therein and that this will comply with the Data Protection Act Page 3 of 5

4 Application Declaration Form continued Are you applying to do this job on job sharing basis? Yes If Possible No (for jobs over 30 hours per week only) If yes, indicate here if you wish your application to be considered as a joint application with someone else, giving his/her name ENTITLEMENT TO WORK IN THE UK Are you currently eligible to work in the UK? Yes No (please tick one) If Yes, and there are conditions attached, for example start and finish dates, please specify the details here: If No, what type of work permit do you require? To comply with the The Immigration, Asylum & Nationality Act 2006 and additional amendments, all prospective employees will be asked to supply evidence of eligibility to work in the UK. We will ask to see and take a copy of an appropriate official document as set out in the Home Office guidelines however do not send these now, further information will be sent to you should you be invited to interview. Please provide your National Insurance Number: CANVASSING OF COUNCILLORS, SCHOOL GOVERNORS (WHERE APPLICABLE) OR SENIOR EMPLOYEES Canvassing of Councillors, School Governors (where applicable) or Senior Employees of the Council, by you or on your behalf is strictly forbidden and may invalidate your application. Please indicate here if you are related to any Councillor, School Governor (where applicable) or Senior Employee of the Council, giving their name (and directorate, if known, where relevant). Please state None if appropriate. of data therein and that this will comply with the Data Protection Act Page 4 of 5

5 Application Declaration Form continued DECLARATION AND DATA PROTECTION STATEMENT If the vacancy you are applying for is subject to a Disclosure and Barring Service (DBS) check, in completing and returning this form you are also confirming the following: I consent to the authority carrying out checks and using information provided from the checks and this application form when making a decision about my suitability to work with or be in regular contact with children/vulnerable adults I understand that the authority will share any information they obtain about me with other organisations where the law requires them to, including where information raises concerns of an adult/child protection nature. I understand that it is an offence to make a statement which is false or misleading in an application for registration. I give consent for the authority to carry out checks and use the information from the declaration and consent form and third party information prescribed in regulations made under the Safeguarding Vulnerable Groups Act 2006, to make a decision about my suitability. To the best of my knowledge, the information I have supplied on this form is correct. I understand that giving false information or omitting relevant information could disqualify my application and, if I am appointed, could lead to an offer being withdrawn or my dismissal. I consent to the information I have provided being verified, which I understand will involve providing relevant documentation for checking and contacting referees/previous employers. of data therein and that this will comply with the Data Protection Act Details of your application including your personal details will be stored in our archives and database for up to 12 months following successful completion of this recruitment process. Please also be aware that the outcome of this application including your name and National Insurance number may be shared with JobCentre Plus (a section of the Department for Work and Pensions) for statistical monitoring purposes only. Signed: Date: of data therein and that this will comply with the Data Protection Act Page 5 of 5