Conflicts of Interest and previous conduct

Please give details of any business or other interests or any personal connections which, if you are appointed, could be misconstrued or cause embarrassment to the Ministry of Justice.

Any particular conflicts of interest detailed here will not prevent you going forward to interview but may, if appropriate, be explored with you during your interview to establish how you would address the issue(s) should you be successful in your application.

Please also confirm if you have every been convicted of, or cautioned for, any criminal offence or have been found guilty of professional misconduct, or if any such proceedings are pending (Please give details, including dates and amount of any fine or other penalty imposed) (NB successful candidates’ final confirmation will be subject to basic clearance checks, covering confirmation of identity and right to work in the UK plus a criminal record check)

I confirm I have read and understood the sections in the candidate pack on ‘Standards in public life’ and ‘Political Activity’.		
(Please tick the above box)

Is this your first public appointment?	Yes:		No:  		

Where did you see this appointment advertised? ……………………………

Public Appointments Currently Held

Please say below if you currently hold any other public appointment posts:

Body	Period of Appointment	Government Department	

			

Requests for referees

Please provide names and contact details of two people who may be asked to act as referees for you, at least one of whom must have knowledge of your work relating to your most recent professional and/ or voluntary activity. They will be expected to have authoritative and personal knowledge of your achievements in a professional or public service capacity.

Reference 1:	
Name:		
Address:		
Telephone:		
Email:		
Reference 2:	
Name:		
Address:		
Telephone:		
Email:		

Please note that for applicants called to interview, we may approach your referees prior to interview.

Declaration

I declare that the information supplied in this application, including that referring to conflicts of interest and previous conduct, is complete and correct to the best of my knowledge. I have also read the information pack and can confirm that I am eligible to be considered for appointment to this body. I also certify that I will immediately inform the Ministry of Justice of any changes in circumstances that affect the answers I have given.		
		
(Please tick the above box)

Note: If you are successfully appointed to the post, a brief summary of your career/experience and details of your response to the Political Activity Declaration may be included in any announcement of your appointment. 

Political Activity Declaration

All applicants should complete the question below. Please indicate which of the following activities you have undertaken during the past five years by ticking the appropriate box and providing details of your involvement. Name the 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, MP, Devolved offices, MEP etc		
Stood as a candidate for one of the above offices		
Spoken on behalf of a party or candidate		
 
Acted as a political agent		
Held office such as Chair, Treasurer or Secretary of a local branch of a party		
Canvassed on behalf of a party or helped at election		
Undertaken any political activity which you consider relevant		

Made a recordable donation to a political party 		

None of the above activities apply.		

Name of Party for which activity undertaken: ……………………………………

Details of your involvement (please continue on a separate sheet if necessary):

Note: this form is for monitoring purposes only and therefore will be detached from your application and will only be seen by the selection panel if selected for interview. 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. 

Diversity Monitoring Form

All Government Departments aim to provide fair and equal access to public appointments and to ensure that all sectors of society are represented. You are requested to complete this form. The questions set out in this form help us to monitor the effectiveness of this policy by gaining a picture of all those applying for and obtaining appointments. They also help us to monitor how we are complying with equality law. 

The Equality Act 2010 protects people from discrimination and promotes equality on the basis of a number of ‘protected characteristics’. We ask for information on your ‘protected characteristics’ in order to help us monitor our performance on equality. 

The government’s commitment to widening access to public appointments is set out in the Diversity Strategy which can be viewed at: www.equalities.gov.uk/news/equality_strategy.aspx or obtained from the Government Equalities Office.

We may also be asked to provide information – in summary form only that does not identify individuals in response to Parliamentary Questions and other public enquiries and reports on our equality performance. 

In line with Government policy, and in accordance with the provisions of the Data Protection Act 1998, the information you provide will be held confidentially and can only be used if you give us your consent. 

The form will be kept separate from your application form and will not be seen by the sift or interview panel. Assessment of your suitability for the post is made purely on the information you give on the application form and your performance at the interview should you be invited. Appointments are made strictly on merit. We hope that this encourages you to complete the form.

Guaranteed Interview Scheme
If you consider yourself to have a disability as defined under the Equality Act 2010 and would like to apply under the Guaranteed Interview Scheme then please complete the Guaranteed Interview Request form and upload with your application.

Should you have any questions, please contact: Phil Ramsden on 020 3334 4014.  

GENDER:
Male		Female		

AGE:
66+              		
56-65           		
46-55           		
36-45           		
35 & under   		

DISABILITY:		
The Disability Discrimination Act as incorporated in Equality Act 2010 defines a person as disabled if they have a physical or mental impairment which has substantial and long term (i.e. has lasted or is expected to last at least 12 months) adverse effect on their ability to carry out normal day-to-day activities. Adverse effects may arise from external barriers experienced by people with impairments.

When you answer the question, you should not take into account the effect of any medication or treatments used or adjustments made (for example at work or at home) which reduce the effects of impairments.  Instead, you should think about the effect the impairment would have if these were not being used or made. 

Taking this into account, do you consider yourself to be a disabled person?

Yes:		No:  		

ETHNIC ORIGIN:
Which group do you identify with? Please tick one box. The options are listed alphabetically.

ASIAN OR ASIAN BRITISH
Bangladeshi		
Indian            		
Pakistani		
Any Other Asian background (specify if you wish)

BLACK OR BLACK BRITISH
African		
Caribbean		
Any Other Black background (specify if you wish)

CHINESE OR OTHER ETHNIC GROUP
Chinese        		
Any Other (specify if you wish)

MIXED
Asian and White                   		
Black African and White       		
Black Caribbean and White  		
Any other Mixed Ethnic Background (specify if you wish)

WHITE  
White		
Any Other White Background (specify if you wish)

ANY OTHER BACKGROUND
Any other ethnic background (specify below if you wish)

Prefer not to say   		

SEXUAL ORIENTATION - Do you consider yourself to be:
Bisexual                		
Gay man               		
Gay woman           		
Heterosexual         		
Other (Please state below)

Prefer not to say   		

RELIGION AND BELIEF - What is your religion?:
None        		
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)    		
Buddhist		
Hindu        		
Jewish       		
Muslim       		
Sikh           		
Other (Please state below)

Prefer not to say   		

Sectoral background - Is your working background?:
Mostly private		
Mostly Civil Service		
Mostly wider public sector		
Mostly Third Sector		
Mixed		
Prefer not to say		

Guaranteed Interview Scheme Declaration

I consider myself to have a disability as defined under the Equality Act 2010, and I would like to apply under the Guaranteed Interview Scheme.

I do/do not require any special arrangements to be made for me to be able to attend or interview. (Please state any such reasonable adjustments below if applicable).

Name:__________________________________________
Date:__________________________
Signature:_______________________________________*

*There is no need for a signature if you are submitting the form electronically.

Please return the completed form with your application.