Application to join our Team

Office use only: Candidate Number Click or tap here to enter

text.

Please read the job description, person specification and Tips on Completing this Application
Form before you begin.

If you would prefer to complete this form in writing, please email businesssupport@backup-
charity.org.uk

What position(s) are you applying for ? If Click or tap here to enter text.
applying for more than one, list them all

Where did you see this job advertised ? Click or tap here to enter text.

Were you advised of this position by a Click or tap here to enter text.
friend/family member? If yes, please
provide their name and work email
address.

Personal Details
This information will not be shared with the Shortlisting Panel

Title: Mr ☐ Ms ☐ Other ☐ Give title: Click or tap here to enter text.

First Name Click or tap here to enter Middle Name(s) Click or tap here to enter text.
text.

Last name Click or tap here to enter text.

Address Click or tap here to enter text.

Postcode Click or tap here to

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 enter text.

Telephone (Day) Click or tap here to Telephone (evening) Click or tap here to enter
enter text. text.

Email address Click or tap here to enter text.

If you have previously used any other first name or last name you must declare all of them
below and state the date of each change and the reason.

Previous Name(s) Date used from Date used to (day, Reason for change
(day, month, year) month, year)

Click or tap here to Click or tap to enter Click or tap to enter Click or tap here to
enter text. a date. a date. enter text.

Click or tap here to Click or tap to enter Click or tap to enter Click or tap here to
enter text. a date. a date. enter text.

Click or tap here to Click or tap to enter Click or tap to enter Click or tap here to
enter text. a date. a date. enter text.

Click or tap here to Click or tap to enter Click or tap to enter Click or tap here to
enter text. a date. a date. enter text.

Click or tap here to Click or tap to enter Click or tap to enter Click or tap here to
enter text. a date. a date. enter text.

Do you have any outstanding safeguarding investigations or suspensions, criminal

prosecutions or convictions that might lead to your being barred from working with children
or vulnerable adults ?
Yes ☐ No ☐
If yes, please give details:

Click or tap here to enter text.

Do you have any convictions, cautions, reprimands or final warnings that might lead to your
being barred from working with children or vulnerable adults ?

Yes ☐ No ☐
If yes, please give details:

Click or tap here to enter text.

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DBS Update Service
As BACKUP provides services that are registered by Ofsted, the charity expects all staff to
register for the DBS Update Service within 30 days of their DBS certificate being issued to
them. (See www.gov.uk/dbs-update-service) The costs of this are reimbursed by the
charity.

If you are unable to use the DBS Update Service, please provide details:

Click or tap here to enter text.

Support at interview
This information will not be shared with the Shortlisting Panel

Do you consider yourself to have a disability ? Yes ☐ No ☐

If you have a disability, please tell us if there are any ‘reasonable adjustments’ we can
make to assist you in your application or with our recruitment process.

Click or tap here to enter text.

Criminal Offences
Exemption under the Exemptions Order to the rehabilitation of Offenders Act 1974

Have you ever been convicted of any criminal offence ? Yes ☐ No ☐

This post involves working with young people. It is therefore exempt from the
Rehabilitation of Offenders Act. You must declare any convictions, including pending
convictions, cautions, reprimands and warning(s) which would otherwise be regarded as
‘spent’ under this Act.

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 Blank page
(application continues after this page)

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 Equality and diversity monitoring form -
recruitment

Office use only: Candidate Number Click or tap here to enter text.

This information will not be shared with the Recruitment Panel

BACKUP North West wants to support equality and diversity in all its employment practices. This
includes not discriminating under the Equality Act 2010 and building an accurate picture of the
make-up of our recruitment applicants and our workforce. The charity needs your help and
cooperation to enable us to profile our job applicants, but filling in this form is voluntary and your
job application will not be affected in any way.

The information provided in this form is kept separately from the information used in recruitment
decisions and will not be used to influence recruitment decisions. All information is strictly
confidential, and only used for statistical purposes to ensure that our policies are being applied fairly.
It will only be shared with a restricted number of authorised personnel and will be destroyed when it
is no longer needed. For more information about our privacy policy please visit (https://backup-
charity.org.uk/)
Sex Male Female Prefer not to say
If you prefer to use your own term, please specify here ……………………………………....
Does current identity match your sex as registered at birth ?
Yes No Prefer not to say
Are you married or in a civil partnership? Yes  No  Prefer not to say 
Age 16-24 25-29 30-34 35-39 40-44  45-49
50-54 55-59 60-64 65+ Prefer not to say
What is your nationality? ........................
What is your ethnicity?
Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you
perceive you belong. Please tick the appropriate box:

White
English Welsh Scottish Northern Irish Irish
British Gypsy or Irish Traveller Prefer not to say
Any other white background, please write in: ……………………………

Mixed/multiple ethnic groups

White and Black Caribbean White and Black African White and Asian
Prefer not to say Any other mixed background, please write in: …………………….

Asian/Asian British

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Indian Pakistani Bangladeshi Chinese Prefer not to say
Any other Asian background, please write in: ………………………………………… …

Black/ African/ Caribbean/ Black British

African Caribbean Prefer not to say
Any other Black/African/Caribbean background, please write in: ………………………………

Other ethnic group

Arab Prefer not to say Any other ethnic group, please write in: ……………………

Do you consider yourself to have a disability or long-term health condition?

Yes No Prefer not to say

The Equality Act of 2010 defines disability as: “a physical or mental impairment with long term,
substantial adverse effects on ability to perform day to day activities.”

PLEASE NOTE the information in this form is for monitoring purposes only. If you believe you need a
‘reasonable adjustment’ during the recruitment process, then please separately notify BACKUP.
What is your sexuality?
Heterosexual Gay Lesbian Bisexual Prefer not to say
If you prefer to use your own term, please specify here ………………………….…….
What is your religion or belief?
No religion or belief Buddhist Christian Hindu Jewish
Muslim Sikh Prefer not to say If other religion or belief, please write in:
…………………………
Do you have caring responsibilities? If yes, please tick all that apply
None
Primary carer of a child/children (under 18) Primary carer of disabled child/children
Primary carer of disabled adult (18 and over) Primary carer of older person
Secondary carer (another person carries out the main caring role) Prefer not to say

Have you been on maternity leave, adoption leave or parental leave in the last year; or have you
been pregnant in the last year; or are you currently pregnant?
Yes No Prefer not to say

Lived Experience

BACKUP is keen to ensure that we attract people with direct experience of the services we
provide and who can therefore offer a different level of understanding and empathy. Have
you (mark all that apply):
 ever been homeless ?
 ever been threatened with homelessness ?

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  ever lived in a property provided by an organisation providing services to homeless
people ?
 ever been looked after by a local authority ?
 ever misused drugs or alcohol (i.e. needed a formal intervention to get your life back
on track) ?

Declaration

I confirm that to the best of my knowledge the information I have provided on this form is
correct and I accept that providing deliberately false information could result in my
dismissal.

I understand also that should my application be successful I will be required to cooperate

with BACKUP in obtaining an Enhanced disclosure of criminal convictions and in checking
my barred status with the Disclosure and Barring Service.

I agree that should I be successful in this application, BACKUP may apply for references
from the people I have named below.

I confirm that I am happy for BACKUP North West to contact me using the contact
information I have provided and to process the personal data I have supplied, including any
sensitive data, in the ways set out in the charity’s privacy policy (https://backup-
charity.org.uk/) and in compliance with data protection law.

Signature: Click or tap here to enter text.

Full Name: Click or tap here to enter text.

Date: Click or tap here to enter text.

Return this completed form to: [email protected]

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Office use only: Candidate Number Click or tap here to enter
text.

Education, job related qualifications and training

Please read the job description and person specification for details of the qualifications needed for this role and make sure you list them if you have
them.

Name of School / Address Qualifications Awarded / Training completed Date Qualifications

College / University Awarded / Training
completed

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a

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Name of School / Address Qualifications Awarded / Training completed Date Qualifications
College / University Awarded / Training
completed

enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

Click or tap here to Click or tap here to enter text. Click or tap here to enter text. Click or tap to enter a
enter text. date.

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Please note: you will be expected to produce any certificates / qualifications listed above. A failure to do so may result in any offer of
employment being withdrawn.

Education
Are you studying at the moment ? Yes ☐ No ☐ If yes, please tell us:

Name of University / College Address Name of Course / Qualification Start date Date Course is due
you are undertaking to end

Click or tap here to enter text. Click or tap here to enter Click or tap here to enter text. Click or tap to enter Click or tap to enter
text. a date. a date.

Click or tap here to enter text. Click or tap here to enter Click or tap here to enter text. Click or tap to enter Click or tap to enter
text. a date. a date.

Are you intending to continue studying if you are successful in this appointment ? Yes ☐ No ☐

Are you intending to begin studying if you are successful in this appointment ? Yes ☐ No ☐ If yes, please tell us:

Name of University / College Address Name of Course / Qualification Start date Date Course is due
you are undertaking to end

Click or tap here to enter text. Click or tap here to enter Click or tap here to enter text. Click or tap to enter Click or tap to enter
text. a date. a date.

Click or tap here to enter text. Click or tap here to enter Click or tap here to enter text. Click or tap to enter Click or tap to enter
text. a date. a date.

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Please advise if you need any adjustments to be made to your work pattern to enable you to continue with / begin your studies (we will try
to accommodate these where practical and appropriate, but may not be able to do so):

(application continues after this page)

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 Employment
Are you working at the moment ? Yes ☐ No ☐ If yes, please give details:

Present job

Name of Employer Click or tap here to enter text.

Job Title Click or tap here to enter text.

Address Click or tap here to enter text.

Postcode Click or tap here to

enter text.

Telephone Click or tap here to enter text.

Website Click or tap here to enter text.

Email address Click or tap here to enter text.

Summarise your main duties and responsibilities:

Click or tap here to enter text.

Start date of employment

(day, month, year) Click or tap to enter a date.

Reason for leaving: Click or tap here to enter text.

Notice period: Click or tap here to enter text.

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Work history

Have you ever been dismissed by any employer ? Yes ☐ No ☐

Please give details of all of your previous jobs and voluntary work. If you have worked at BACKUP North West before, please include details of
that job also. If you cannot remember the exact day that you started or left a job, please just give it a rough estimate. (You can get a record of
your current and past 5 years’ employment by downloading the HMRC App from www.gov.uk/guidance/download-the-hmrc-app or by using
the Government Gateway to register for a range of services provided by the UK government www.access.service.gov.uk/login/signin/creds.

Name of Employer Address Job Title Date you Date you left Reason for leaving (please
started in this this role (day, also state if you were
role (day, month, year) dismissed)
month, year)

Click or tap here to enter Click or tap here to enter Click or tap here to Click or tap to Click or tap to Click or tap here to enter
text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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Name of Employer Address Job Title Date you Date you left Reason for leaving (please
started in this this role (day, also state if you were
role (day, month, year) dismissed)
month, year)

Click or tap here to enter Click or tap here to enter Click or tap here to Click or tap to Click or tap to Click or tap here to enter
text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

Application for Employment 15 | P a g e o f 2 0

Name of Employer Address Job Title Date you Date you left Reason for leaving (please
started in this this role (day, also state if you were
role (day, month, year) dismissed)
month, year)

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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text. text. enter text. enter a date. enter a date. text.

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 Gaps in employment
If there any gaps in your employment history that are longer than one week (that is gaps
between studying, working and any voluntary jobs), please explain them below. This can
be anything including:
 Redundancy
 Dismissal
 Maternity leave
 Caring for family members
etc.

Date From (day, Date To (day, month, Reason for gap

month, year) year)

Click or tap to Click or tap to enter a Click or tap here to enter text.
enter a date. date.

Click or tap to Click or tap to enter a Click or tap here to enter text.
enter a date. date.

Click or tap to Click or tap to enter a Click or tap here to enter text.
enter a date. date.

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enter a date. date.

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enter a date. date.

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enter a date. date.

Click or tap to Click or tap to enter a Click or tap here to enter text.
enter a date. date.

Application for Employment 17 | P a g e o f 2 0

 Other experience
Is there any other relevant experience that you want us to consider ?

Click or tap here to enter text.

Why do you want this job and why do you want to work for BACKUP ? (We
suggest you write no more than 200 words.)

Click or tap here to enter text.

Describe your experience of providing the key responsibilities listed for this
this job role.

Click or tap here to enter text.

Describe how you meet the Person Specification for this job role.
This is the most important question, tell us how you meet all of the criteria listed in each
area of the person specification.

EDUCATION / QUALIFICATIONS:
Click or tap here to enter text.

KNOWLEDGE / WORK EXPERIENCE / SKILLS:

Click or tap here to enter text.

PERSONAL SKILLS / SPECIAL ATTRIBUTES (CHARACTERISTICS / QUALITIES):

Click or tap here to enter text.

Other requirements of this job role

Are you permitted to work in the UK without applying for

a work permit ? Yes ☐ No ☐

If you secured this position, would you continue in any

other employment ? Yes ☐ No ☐

Does the job description state that you need a car for
work purposes ? Yes ☐ No ☐

If “yes”:

Do you have sole use of a car during work hours ? Yes ☐ No ☐

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 Do you have a current Full UK Driving Licence ? Yes ☐ No ☐

Do you have any current endorsements ? Yes ☐ No ☐

Do you have any motoring prosecutions pending ? Yes ☐ No ☐

If you do not have a vehicle available for work purposes, it is still possible for you to
apply for the role provided you can explain how you will complete the required tasks.
Please tell us how you will complete your duties without use of a car:

Click or tap here to enter text.

References
Give the details of two people who we can contact about your suitability for the post.
One of these must be your present or most recent employer and you cannot use family
members.
We will only contact your references if you are offered the post.

Reference 1

First Name Click or tap here to enter Surname Click or tap here to enter text.
text.

Job Title Click or tap here to enter text.

Address Click or tap here to enter text.

Postcode Click or tap here to

enter text.

Telephone Click or tap here to enter text.

Email address Click or tap here to enter text.

In what capacity does this person Click or tap here to enter text.
know you ?

Reference 2

First Name Click or tap here to enter Surname Click or tap here to enter text.

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 text.

Job Title Click or tap here to enter text.

Address Click or tap here to enter text.

Postcode Click or tap here to

enter text.

Telephone Click or tap here to enter text.

Email address Click or tap here to enter text.

In what capacity does this person Click or tap here to enter text.
know you ?

Return this completed form to:

[email protected]

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