Application Form

Ambassador to Office for Disability Issues promoting the role and value of disabled people in the local community based in NW England, Scotland and Wales
This application form is separated into 8 sections (17 pages, including this cover page). Please read each page carefully and ensure every question is completed. If you are handwriting your application form, please make sure your writing is legible. Please use black ink as this photocopies best. We are keen to make reasonable adjustments for applicants. If you would like to use another format for your application, please contact us. Applications should be sent to: Audrey Daft, Ground Floor, Caxton House, Tothill Street, London SW1H 9NA. This can either be by e-mail or by post. Emailed applications should be sent to: Audrey.daft@DWP.GSI.GOV.UK The closing date for applications is 8th June 2012 at 10am. Late applications will not be considered. There will not be a guaranteed interview for disabled people who do not meet the minimum criteria. As we are expecting a lot of interest in these posts we expect the calibre of applications to be very high. Can you tell me where you heard about this role? Disability Now Y/N Guardian/Times Newspaper Y/N On the Office for Disability Issues Website Y/N Twitter/Facebook Y/N Other (please give details)

Section 1: Personal Details

Role Reference Number: Title (Mr/Mrs/Miss/Ms/Other (please specify): Name: Home Address:

Home Telephone: Mobile Telephone: E-mail address: Please add any other contact details (if applicable) and state your preferred means of contact e.g. telephone, email etc:

Please list any dates when you will be unavailable between Monday 2nd July and Monday 9th July 2012.

I have read the definition of a disabled person in the Candidate Information pack and consider that I am a disabled person for the purpose of this application. Please indicate as appropriate: Yes No There will not be a guaranteed interview for disabled people who do not meet the minimum criteria. As we are expecting a lot of interest in these posts we expect the calibre of applications to be very high.

Section 2: Knowledge and Experience

Please respond to each of the criteria numbered 1-8 below. Please provide examples of your knowledge and experience and the outcomes you have achieved to demonstrate your suitability. Please limit your examples for each criterion to 400 words. The boxes will expand as you type. If you are writing your application form, you may continue on additional sheets if required. Criteria 1) Experience of working within local communities to increase disabled peoples participation and demonstrate an understanding of local issues affecting disabled people. Supporting evidence

Criteria 2) Demonstrate a good understanding of the barriers faced by disabled people in obtaining and retaining main stream employment. With evidence of how you have supporting disabled people to overcome these barriers. Supporting evidence

Criteria 3) The ability to work with a range of people, especially government officials and voluntary sector organisations. In particular a proven track record of influencing decisions and negotiating to deliver positive outcomes Supporting evidence

Criteria 4) Demonstrate good interpersonal skills with a personal style that is incisive and challenging, but not confrontational. Supporting evidence

Criteria 5) Ability to develop project plans to deliver services to make a real difference in the community and to submit funding bids. Supporting evidence

Section 3: Additional Information

This section is for you to note any additional information you want to include in support of your application. This can include details of your career history (if applicable) and other relevant experience, such as: employment, voluntary experience, involvement in the community, committee experience, or caring responsibilities. It should include any public appointments you have held. Alternatively, for this section only, you may provide a CV (maximum 2 pages). 1) Name and Address of Employer or Organisation

Title / Positions Held

Details (Including Nature of Work and Time Commitment)

Dates From and To

2) Name and Address of Employer or Organisation

Title / Positions Held

Details (Including Nature of Work and Time Commitment)

Dates From and To

3) Name and Address of Employer or Organisation

Title / Positions Held

Details (Including Nature of Work and Time Commitment)

Dates From and To

Section 4: Register of Interest Form

Please submit a signed copy of the Register of Interest form which addresses the issues of conflicts or improprieties, past or present that would impact on your ability to carry out this role. Full Name: Position: Please register any links and relationships with organisations, individuals or bodies that may give rise to a potential conflict of interest. Directorships Please list all Directorships (held within the last two years), with a brief description of the company and any possible links to DWP or any other Government Departments (directly or indirectly). Please include any partnerships. 1) Company Possible Links to DWP Date of Appointment Date of Resignation

2) Company Possible Links to DWP Date of Appointment Date of Resignation

3) Company Possible Links to DWP Date of Appointment Date of Resignation

Other Public Appointments 1) Role Possible Links to DWP Date of Appointment Date of Resignation

2) Role Possible Links to DWP Date of Appointment Date of Resignation

3) Role Possible Links to DWP Date of Appointment Date of Resignation

Close relations and friends Please list any possible conflicts of interests created by virtue of the employment, directorships or significant shareholding of a close relation or friend. 1) Name Company Possible Links to DWP Relationship to Senior Manager

2) Name Company Possible Links to DWP Relationship to Senior Manager

3) Name Company Possible Links to DWP Relationship to Senior Manager

4.

Any other matter

Please list any other matter, which may give rise to a potential conflict of interest e.g. related consultancy contracts, external examinerships with academic institutions, membership of committees/organising bodies with decision making or purchasing powers, including Trusteeship of charitable or other bodies. 1) Name Company Possible Links to DWP Relationship to Senior Manager

2) Name Company Possible Links to DWP Relationship to Senior Manager

3) Name Company Possible Links to DWP Relationship to Senior Manager

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I certify that the information included within this register is, to the best of my knowledge and belief true and accurate and complete. Name: Signature: (If sent by email please state here.) Date: Please insert your full name in the box above to declare that the information given in this Register of Interest form is complete and correct.

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Section 5: Referees
Please provide names and contact telephone numbers of two people, who may be called to act as referees for you. They must have authoritative and personal knowledge of your recent achievements in a professional or public service capacity. References will be taken up after short listing and in advance of the final interview. Please provide details of the most accessible way to contact them.

1) Name Contact Details

2) Name Contact Details

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Section 6: Personal Consent

Please sign the following declaration: I declare that the information given in this application form is complete and correct. I have read the information pack and can confirm that I am eligible to be considered for appointment to this body. I understand that if any of the information provided in this form is untrue I may be removed from office. I certify that I will immediately inform the Department of any changes in circumstances that affect the answers I have given. I also confirm consent to share the information in this form with members of the panel, Ministers, those responsible for the recruitment process in DWP. This information will be handled in line with the Data Protection Act 1998 and will be used solely for the purposes of assessing suitability for this role. Some of the information supplied will be placed in the public domain if successful.

Name: Signature: (If sent by email please state here.) Date: Please insert your full name in the box above to acknowledge you have read and understood the declaration of personal consent.

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Section 7: Political Activity Question

All applicants for a public appointment should complete the question below. This question is asked as it enables the monitoring of political activity of candidates for a public appointment in so far as it is already in the public domain. Neither activity nor affiliation is a criterion for appointment (except where statute dictates specific representation). If you are successful, the information provided will be published with the announcement of your appointment. Please indicate which of the following activities you have undertaken during the past five years by ticking the appropriate box and by providing details of your involvement. Name the political party or body for which you have been active. If you have been or are an Independent or have sought or obtained office as a representative of a particular interest group, you should state this. You should tick all relevant categories.

Obtained office as a Local Councillor, District Councillor, MP, MEP, MLA etc.

Acted as a political agent

Held Office such as Chair, Treasurer or Secretary of a local branch

Undertaken any other political activity which you consider relevant

Made a recordable donation to a political party

None of the above activities

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Name of Party for which activity undertaken: Details of involvement: Name: Signature: (If sent by email please state here.) Date: Note: This form is for monitoring purposes only and therefore will be detached from your application and will not be seen by any selection panels. However, it is appreciated that such activities may have given you relevant skills, including experience gained from committee work, collective decision making, resolving conflict and public speaking. If, therefore, you have had such experience and you consider it relevant to your application for this post, you should include it separately in the main body of your application form. You should not, however, identify the relevant political party in the application form.

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Section 8: Equal Opportunities

All Government Departments aim to provide fair and equal access to public appointments. Questions on gender, ethnic origin, age and disability will help the Department to monitor the effectiveness of its strategy through information from those applying for and obtaining appointments. This form will not be seen by the selection panel. Your answers will be treated confidentially and will not affect your application in any way. Alternatively, the form can be returned uncompleted if you do not wish to have these details recorded.

Ethnic Origin Information These categories are not about nationality, place of birth or citizenship. They relate to broad ethnic group categories as recommended by the EHRC. When you have read them all please tick the box that most accurately describes you. Asian or Asian British: Indian Pakistani Bangladeshi Other Black or Black British: Caribbean African Other Chinese or Other: Chinese Other Mixed: White and Black Caribbean White and Black African White and Asian Other White: British Irish Other 16

Other Ethnic Origin (please describe) Age Are you? 16-25 26-35 36-45 46-55 56+ Prefer not to say Gender Are you? Male Female Prefer not to say

Sexual Orientation Are you? Heterosexual Lesbian/Gay Bisexual Asexual Prefer not to say

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