Postal Code:
Do you hold a current driver’s licence?
Do you drive a car?
Are there any restrictions on your taking up work in the UK?
Name of employer:
Please give details of your full employment history. Also, please detail any periods of unemployment and unpaid/voluntary work (most recent first).
Dates From / To Name and address of organisation Telephone and contact Job/Role and brief description of main duties Reason for leaving


Name of School/College/ University/ Awarding Body Type of School/ Establishment (secondary, sixth form, university) Qualifications (If shortlisted you will be required to provide proof of any relevant qualifications) Grade/ Level


Dates Course title and duration


Your current/most recent line manager/employer
May we approach this referee prior to interview?
May we approach this referee prior to interview?


Declaration under the Protection of Freedoms Act 2012 and the Childcare Act 2006. The post for which you are applying is a ‘regulated activity’ within the meaning of Part 5 Chapter 1 of the Protection of Freedoms Act 2012 and it is a criminal offence for a ‘barred person’ to apply to work in a regulated activity. It is also an offence under Section 76 of the Childcare Act 2006 for a ‘disqualified person’ to work in childcare. If you are a barred or disqualified person you must not proceed with this job application. If your application is successful, you will be required to co-operate with us in obtaining a disclosure of criminal convictions from the Disclosure and Barring Service and in checking your status with Ofsted.


Are you a barred or disqualified person? Yes / No Are you knowingly living in the same household as a barred or disqualified person or where a barred or disqualified person is employed, or do you have any outstanding criminal prosecutions or convictions that might lead to you being barred or disqualified from working with children?

Yes / No If “Yes”, give full details:

Do you have any convictions, cautions, reprimands or final warnings that would not be filtered in line with current guidance?

Yes / No If “Yes”, give full details:

If you have previously had any other surname(s) or forename(s), you must declare all of them below and state the date of each change and the reason

MM slash DD slash YYYY



Because this position involves working in the environment of caring for children, employment is dependent on the following:

1. Your written consent to obtaining a standard/enhanced disclosure certificate from the
Disclosure & Barring Service or an approved umbrella body.
2. Such disclosure being acceptable to us.
3. Proof of identity – birth or marriage certificate (where appropriate) and passport (if available).
4. Two satisfactory written reference.
5. Evidence of physical or mental suitability for your work

DECLARATION (Please read this carefully before signing this application)

1. I confirm that the above information is complete and correct and that any untrue or misleading information will give
my employer the right to terminate any employment contract offered.

2. Should we require further information and wish to contact your doctor with a view to obtaining a medical report,
the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree
that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this
information will be retained in my personnel file during employment and for up to six years thereafter and
understand that information will be processed in accordance with the Data Protection Act.

3. I agree that, should I be successful in this application, I understand that Great West Day Nursery 
Nurseries will need to apply to the Disclosure & Barring Service for an enhanced disclosure. I understand that, should
the disclosure is not to be the satisfaction of the company, any offer of employment may be withdrawn or my
employment terminate.