ADVANTAGE ANGELS – CRIMINAL DECLARATION

Full Name

Position Applied For

1. Have you ever been convicted by the courts or cautioned, reprimanded, or given a final warning by the police? Please give details of offences, penalties and dates in the table below. *(Note that the post you have applied for is exempted under the Rehabilitation of Offenders Act (Exceptions Order) 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need to be disclosed. 1. Have you ever been convicted by the courts or cautioned, reprimanded, or given a final warning by the police? Please give details of offences, penalties and dates in the table below. *(Note that the post you have applied for is exempted under the Rehabilitation of Offenders Act (Exceptions Order) 1974, which means that all convictions, cautions, reprimands and final warnings on your criminal record need to be disclosed. Yes (Please provide details below) No (Proceed to Q2)

Details (including dates)

2. Have you ever been disqualified from work with vulnerable adults or sanctions imposed by any regulatory body? 2. Have you ever been disqualified from work with vulnerable adults or sanctions imposed by any regulatory body? Yes (Please provide details below) No (Proceed to Q2)

Details (including dates)

3. Please sign the following declaration and return this form to Human Resources with your application. Failure to complete this declaration will result in your application being withdrawn. 3. Please sign the following declaration and return this form to Human Resources with your application. Failure to complete this declaration will result in your application being withdrawn. I confirm that the information I have given on this form is correct and complete and I understand that any false information could result in my application being rejected or, if appointed, in my dismissal. I understand that any offer of work made to me will be subject to a further check with the Disclosure and Barring Service (previously Criminal Records Bureau) and I hereby give my consent for Coram to carry out the relevant DBS status checks in line with the DBS Code of Practice. I declare that I am not currently on the DBS Barred List and that I will notify the Human Resources department immediately if I do become barred in future.

Signed:

Date: