Domestic Abuse Safety Unit
APPLICATION FORM
Better Options – Greater Safety
Volunteer Co-ordinator PART I
1. Please use this form to give us as much information as you can.
All information on this form is strictly confidential.
Name:
(Please indicate)
Mr / Mrs / Ms / Miss
Home Address:
Tel No: Day:
Mobile:
Evening
Email:
Employer:
Address:
2. Do you have a driving licence? YES / NO
3. Do you have use of a car? YES / NO
4. Do you speak Welsh? YES / NO
All applicants will have to undergo checks by the Disclosure and Barring service before an
offer of a post with DASU is finalised.
5. Have you EVER been convicted of any criminal offence? YES / NO
If YES please give details below. A conviction, bind over or caution will not automatically
disqualify you from working with DASU, but failure to disclose could result in an offer of
employment being withdrawn or a dismissal. DASU is exempt from the Rehabilitation of Offenders
Act (1974) due to working with vulnerable people. Information is treated with the strictest of
confidence.
Please give details of Offence / Circumstances and Date
1
Wrenmore House, 104, Chester Road East, Shotton, Deeside, Flintshire CH5 1QD.
Tel: 01244 830436 Fax: 01244 810505 Web: www.domesticabusesafetyunit.net
Domestic Abuse Safety Unit
APPLICATION FORM
Better Options – Greater Safety
Volunteer Co-ordinator PART I
6. Please supply the names and addresses of two referees. It is essential that one of
your referees is your current or most recent employer. In addition, DASU reserve the
right to contact any previous employers for information.
Please indicate that you agree to this YES / NO
(An offer of work with this organisation is conditional upon satisfactory references, work
history checks and Enhanced DBS check).
Name:……………………………….
Name:…………………………………..
Address:…………………………….
………………………………………....
………………………………………….
…………………………………………
Address:……………..…………………
………………………………..
….……………………………
….………………………………
Telephone No:………………………
In what capacity do you know this person?
……………………………………………………….
May we contact this referee now? YES/NO
Signature………………………………………..
Telephone No:…………………………
In what capacity do you know this person?
…………………………………………………
May we contact this referee now? YES/NO
Date………………………………….
You will be required to provide proof of identity eg. Passport, photo driving licence) along
with evidence of qualifications and training when you attend for an interview.
The information provided throughout this application is true and correct.
Once completed please post or email all parts of your application marked ‘Private &
Confidential’ to arrive no later than 4pm on 22nd of March 2017 to Rachael Roberts,
One Stop Shop Coordinator, Domestic Abuse Safety Unit, at the address below or by
email to [email protected]
2
Wrenmore House, 104, Chester Road East, Shotton, Deeside, Flintshire CH5 1QD.
Tel: 01244 830436 Fax: 01244 810505 Web: www.domesticabusesafetyunit.net
Domestic Abuse Safety Unit
APPLICATION FORM
Better Options – Greater Safety
Volunteer Co-ordinator PART I
EQUAL OPPORTUNITIES MONITORING
The Domestic Abuse Safety Unit is
committed to developing equal
opportunities in all matters of employment
and service delivery. To help us monitor
equal opportunities in relation to
recruitment, your co-operation in
completing this form is appreciated.
Any information provided will be used for
monitoring purposes only and will be
separated from your main application
immediately upon receipt and shredded
once analysed.
Position applied for
__________________________
How did you hear about this post?
__________________________
If through an advertisement, which
publication?
__________________________
Date of Birth
__________________________
Gender
Please tick the appropriate boxes
Male Female
Physical/Disability/Medical condition
Are you registered disabled?
Yes No
Do you consider you have a disability?
No known disability
Dyslexia
Blind or partially sighted
Deaf or hearing impaired
Wheelchair user/mobility difficulties
Personal care support
Mental health difficulties
Unseen disability e.g. Diabetes, epilepsy
Autistic spectrum disorder
3
Unseen disability e.g. Diabetes, epilepsy
Autistic spectrum disorder
Disability not listed above (please specify)
Information declined
Ethnic Classification
Please tick the appropriate box to indicate
your cultural background.
White
British
Irish
Other* _________________
Asian or Asian British
Indian
Pakistan
Bangladeshi
Asian Other* ______________
Black or Black British
Caribbean
African
Black Other* ______________
Chinese or Other Ethnic
Chinese
Chinese Other* ____________
Mixed
White & Black Caribbean
White & Black African
White & Asian
Mixed Other* ______________
* Please specify
Information declined
Thank you for providing this
Information
Wrenmore House, 104, Chester Road East, Shotton, Deeside, Flintshire CH5 1QD.
Tel: 01244 830436 Fax: 01244 810505 Web: www.domesticabusesafetyunit.net
Domestic Abuse Safety Unit
APPLICATION FORM
4
Better Options – Greater Safety
Volunteer Co-ordinator PART I
Wrenmore House, 104, Chester Road East, Shotton, Deeside, Flintshire CH5 1QD.
Tel: 01244 830436 Fax: 01244 810505 Web: www.domesticabusesafetyunit.net