Safeguarding

These questions were recommended by the NSPCC, and we ask that you fill them in to help us keep our young people safe.

We do this because your role at Company Three is exempt from the Rehabilitation of Offenders Act 1974 in England, Scotland and Wales, or the Rehabilitation of Offenders (Northern Ireland) Order 1978 and involves contact with children or young people.

This information will be stored confidentially and reviewed by our Designated Safeguarding Lead and Deputy Designated Safeguarding Lead.

Name

First Name

Last Name

Previous Name(s)

Job role you are applying for

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

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###

####

Date of Birth

MM

DD

YYYY

CRIMINAL RECORD DECLARATION

This role is covered by the Rehabilitation of Offenders Act 1974 in England, Scotland and Wales, or the Rehabilitation of Offenders (Northern Ireland) Order 1978. You are therefore only required to declare unspent conditional cautions or convictions.

Do you have any unspent conditional cautions or convictions in the UK or overseas?

If yes, please provide further information:

CONDUCT DECLARATION

Have you ever been known to any children’s services department or police as being a risk or potential risk to children?

If yes, please provide further information:

Have you ever been dismissed for misconduct from any paid or voluntary position previously held by you?

If yes, please provide further information:

Have you ever been under investigation for or subject to any disciplinary sanctions in relation to your conduct at the time of your employment?

If yes, please provide further information:

Have you ever been subject to any sanctions being placed on your professional registration, by a regulatory or licencing body in any country? (as applicable)

Sanctions may include: Warnings, conditions, limitations, suspensions removal or any other restrictions that may have applied to your professional registration.

If yes, please provide further information:

CONFIRMATION OF DECLARATION

Please tick to ensure you agree to the following

I agree that the information provided here may be processed in connection with recruitment purposes and I understand that an offer of employment may be withdrawn or disciplinary action may be taken if information is not disclosed by me and subsequently come to the organisation’s attention.

In accordance with the organisation’s procedures if required I agree to provide a valid criminal record certificate and consent to the organisation clarifying any information provided on the disclosure with the agencies providing it.

I agree to inform the organisation within 24 hours if I am subsequently investigated by any agency or organisation in relation to concerns about my behaviour towards children or young people.

I understand that the information contained on this form, the results of the criminal record check and information supplied by third parties may be supplied by the organisation to other persons or organisations in circumstances where this is considered necessary to safeguard children.

Digital Signature

Signatory's Name

First Name

Last Name

Date Signed

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DD

YYYY