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Forms > Rehabilitation Of Offenders/Criminal Records Declaration Form

Rehabilitation Of Offenders/Criminal Records Declaration Form

A criminal record will not necessarily be a bar to obtaining a position.

Section 1

Post Applied For:

Section 2

Surname:
Forename(s)or other :
Current address
Time at current address: (if less than 5 years see section 3)
Telephone number:
Place of Birth:

Section 3

Please complete if your time at your current address is less than 5 years. Minimum of 5 years required.

Previous Name(s) Previous Address(es) Time at address (years) (months)
Any further addresses:

Section 4

The Rehabilitation of Offenders Act 1974, requires all applicants to declare ‘unspent’ convictions. Please answer the following:
Do you have any ‘unspent’ criminal convictions by the courts? (the accompanying Guidance Notes provide details of spent and unspent convictions)
YesNo

If yes, please give details of the date of the conviction(s), nature of the offence(s) and the sentence(s) imposed:

Section 5

The post you have applied for requires a DBS Standard or Enhanced Disclosure. Healthcare professional, are exempt from the Rehabilitations of Offenders Act 1974 and you are required to declare any ‘spent’ convictions. Please answer the following:

Do you have any ‘spent’ criminal convictions by the courts, or have you been cautioned, reprimanded or given a final warning by the police?
YesNo
If yes, please give details of the date of the conviction(s), nature of the offence(s) and the sentence(s) imposed:

Section 6

Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this post?
YesNo
If yes, please give details:

Section 7

DECLARATION

I certify that the information provided above, is correct. I understand that any false statement or omissions may result in my application being withdrawn or my appointment being terminated.

If I am selected for a post that requires a enhanced disclosure, I give the Elite Live In care Ltd permission to carry out the necessary check with the Disclosure and Barring Service (DBS).

If I am appointed, I undertake to inform Elite Live In Care Ltd immediately if I am convicted of any criminal offence during my employment them.

NOTE: Any information provided will be stored securely in manual form and processed in accordance with the Elite Live In Cares’ registration under the Data Protection Act (1998). For the successful candidate, the information will form part of the personal, confidential record. In the case of unsuccessful candidates, the data will be destroyed after six months.

Print Name:
Date: