Registration Form - Boston Rose - 2010

8/10/2019 Registration Form - Boston Rose - 2010

1/8

DNS Ev1 : Boston Rose 2009 Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963 Company Number 5015384

Registration Form - Education

HQ Ref:

To ensure that your application proceeds smoothly, pre-appointment checks can

be put in place and to help avoid any delay, please:

a) complete all sections of this form in BLACK INK / TYPE and in CAPITALS if hand written

b) note that all sections must be completed by the Applicant

1. Personal Details

Title: Date of Birth:

Surname: Forename(s):

HQ Number (Internal Use Only)

2. Disclosure

Boston Rose are required by CRB regulations to carry out an Enhanced Disclosure Certificate (CRB)

issued by the Criminal Records Bureau or Disclosure Scotland.

Please select one of the following options YES NO

a) I have submitted a copy of my CRB to Boston Rose which is no more than 12

monthsold whilst my new CRB is being processed. I enclose my completed CRB

Application Form.b) I do not hold a current CRB, so have enclosed a completed CRB Application Form

and I have supplied the necessary original ID documentation to you with the

application

(Please ensure you complete section 3 of the registration form if you tick this

option)

Please confirm: YES

Legislation provides that the applicant should pay for the CRB check. No mark up is charged by

Boston Rose.

I enclose a cheque made payable to Boston Rose for 46.00 for the CRB fee

I consent to Boston Rose passing a CRB relating to me onto interested third parties

(such as a College)

*We will not be able to process your CRB until we have received a cheque for the sum above. Prompt payment

will avoid any delays of your start date or cancellation of your appointment.*

Mr. 01/07/1975

HABOOL AL-SHAMERY MAITHAM


2/8


3. Rehabilitation of Offenders Act 1974 (Exceptions) (Amendments) Order 1986 (SI

1986/1249) (ROA)

Please circle as appropriate

Yes / No Have you been convicted of a criminal offence?

Yes / No Do you have knowledge of any pending prosecutions in respect of alleged

criminal offences (excluding road traffic offences not involving injury to a third party) or

a sentence of imprisonment?

Please provide details below if you have answered yes to either of the above:-

Date Offence Sentence

Assignments may mean you are involved in teaching or training students under the age of 18, or

students with learning difficulties or disabilities. Your registration with Boston Rose and your assignment

is therefore classed as exempt from the provisions of the ROA. You may be required to apply for anEnhanced Disclosure police check through the Criminal Records Bureau (an executive agency of the

Home Office) or if in Scotland, the Scottish Criminal Records Bureau. Consequently you are NOT entitled

to withhold information about convictions, which for other purposes are spent under ROA. All

information provided by you in the section below will be checked with the relevant authorities.


3/8


4. Referees

Please nominate two referees, one of whom must be your latest employer. If you have been working

through an agency please provide the contact details for your line manager at your place of work and

not details of the agency.

Boston Rose will take up both references, so if you have any concerns or timing issues relating to us

contacting your referees please indicate so and provide details here:

Current / Most Recent Employer

Contact before position accepted: Yes / No

Name:

Company :

Position Held:

Address:

Postcode:

Tel No:

Fax No:

E-mail address:

Relationship to Applicant:

Previous Employer

Name:

Company :

Position Held:

Address:

Postcode:

Tel No:

Fax No:

E-mail address:

Relationship to Applicant:

Education Referee

Please complete this section if you have worked in the Education sector previously but they are not your

latest employer or previous employer:

Company:

Contact Name:

Contact Position:

Contact Tel:

Contact E-mail:

Dr David Richardson

Faculty of Engineering Design and MathematicsUniversity of the West of England

Senior Lecturer

Faculty of Engineering Design and MathematicsUniversity of the West of EnglandFrenchayBristol

BS16 1QY

0117 328 2223

[email protected]

Programme Manager


4/8


5.Qualifications

Please

1.

List all education, professional & trade qualifications that you have been awarded or are

currently studying for

2. Supply Original Certificates for all qualifications stated3. Use the Continuation Sheet (in the Appendix (Section 5)) as necessary

SCHOOL QUALIFICATIONS

Do you hold a level 2 (GCSE, GCE, CSE Grade 1, Key Skills or equivalent) qualification in:

English? Yes [ ] No [ ]

Mathematics? Yes [ ] No [ ]

QUALIFICATIONS SCHOOL, FURTHER AND HIGHER EDUCATION, TEACHING

From To Institution FT/PT Qualification Grade/Class

PROFESSIONAL or TRADE MEMBERSHIP

Are you registered with the IFL (Institute for Learning)

or GTC (General Teaching Council)?

Please tick as appropriate

IFL Yes [ ] No [ ]

Membership Number:

GTC Yes [ ] No [ ]

Membership Number:

Main teaching subject taught (if applicable):


5/8


6. Health

Anyone appointed to a post involving regular contact with children or young people must be medically

fit (Education (Health Standards) (England) Regulations 2003). Please provide any information about

your past and present health that may affect your ability to undertake tasks while working on an

assignment, including:

any reasonable adjustments that could be made to help you carry out your role

whether you consider yourself disabled

receipt of any incapacity benefits

health conditions affecting your ability to work

medication or conditions that may impair your safety

any health problems that may be of concern when working with children (e.g. mental or

psychological illness, infections or diseases)

any absences from work for health reasons during the last 12 months.

All information supplied will be kept strictly confidential

Health Information

7. Data Protection

Boston Rose complies with the Data Protection Act 1998 and is registered for the processing of

information. Boston Rose may also be able to provide you work and opportunities through group

companies. Please only put an X in the brackets if you do not wish your details to be made available to

other group companies [ ]

8. Equal Opportunities

Boston Rose strives to work within legislative requirements as well as promoting best practice. If you

wish to assist us with Equal Opportunities Monitoring please complete the Form in Appendix 1 which

will be detached from this Application Form and held by HR


6/8


9. Declaration

Information you provide in and together with this Application Form will be checked. It is also your

responsibility to inform us of any significant changes to your circumstances. If Boston Rose reasonably

believes that you have withheld relevant details or provided misleading or false information on or with

this Application Form then your assignment may be terminated without payment on immediate notice,you may be removed from our Database, future references could be affected, Boston Rose may choose

not to introduce you to other assignments and may take any further action it deems appropriate.

Declaration: I declare that all the answers I have given and the information I have provided are

accurate, complete and true to the best of my knowledge and belief, and that Boston Rose may

disclose parts of this application and any accompanying documents with prospective and actual

employers if requested.

Applicant Name (print):_______________________

Signature:__________________________________

Date: _____________________________________

For Boston Rose use only

Reviewed:

Date:

Suitability: Fit/Unfit to work


7/8


Appendix 1) Equal Opportunities Monitoring Form

Boston Rose is committed to equal opportunities. In order to monitor the effectiveness of our Equal Opportunities

Policy, we request that all Applicants complete the section below. This section will be separated from the

Application Form on receipt and kept securely. It will not be passed on to the end client.

Surname Forename

Gender Female Male

Age

Ethnic Origin

Asian/Asian British

Bangladeshi White and Asian

Indian White and Black African

Pakistani Any Other

Any Other

Black/Black British White

African British

Caribbean IrishAny Other Any Other

Other not listed

If you have a disability falling within the terms of the Disability Discrimination Act, for which the end client may

need to make a reasonable adjustment, please provide information below

I give consent to Boston Rose recording and processing information about me in the above categories in order tomonitor the effectiveness of their Equal Opportunities Policy. My consent is conditional upon Boston Rose

complying with the obligations and duties under the Data Protection Act 1998

Signature Date


8/8


Appendix 2) Continuation Sheet

QUALIFICATIONS SCHOOL, FURTHER AND HIGHER EDUCATION, TEACHING

From To Institution FT/PT Qualification Grade/Class

Any other expansion required (please label clearly)

Registration Form - Boston Rose - 2010

Documents

Transcript of Registration Form - Boston Rose - 2010