PMR DBS Form

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Department

Title(Required)

Title (Other)(Required)

Name(Required)

First Middle Last

Date of Birth(Required)

Gender(Required)

NI Number(Required)

Address History (Must date back 5 years)(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date from (Address 1)(Required)

Date to (Address 1)(Required)

Address 2

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date from (Address 2)

Date to (Address 2)

Address 3

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date from (Address 3)

Date to (Address 3)

Additional Addresses

Place of Birth(Required)

Country(Required)

Nationality(Required)

Nationality at birth(Required)

Surname at birth(Required)

Used until(Required)

Previous Names (If applicable you must provide evidence of this – see below)

First Middle Last

Date from

Date to

Reason Why(Required)

Do you have any spent or unspent convictions?(Required)

Yes

If yes please provide a statement below:(Required)

We need 3 forms of ID before we can apply for your CRB. We must have 1 from Group 1 and 2 from group 2 - Please note we MUST have addressed ID! (All utility bills and Statements must be addressed to your current address)

Group 1

Valid Passport (any nationality)
UK Driving License (photo card only valid if paper part present)

Group 2

UK P45/P60 Statement (issued within last the last 12 months)
Bank or Building Society Statement (issued within the last 3 months)
Credit Card Statement (issued within the last 3 months)
UK Mortgage Statement from a recognised lender
Local council rent card or tenancy agreement (issued within the last 3 months)
Utility Bill - electric, gas, water, telephone - must be a landline bill (issued within the last 3 months), we can accept more than one utility bill as long as they are from different suppliers)
Council Tax Statement (issued within the last 12 months)
Benefit Statement, book or card; or original letter from the Department of Work and Pensions (DWP) confirming the rights to benefit – i.e child allowance, pension (issued within the last 12 months)
Confirmation from an electoral register search that a person of that name lives at claimed address (issued within the last 12 months)

Name Changes

If you have declared that you have had name changes you must provide us with evidence of this:

Marriage certificate or Civil partnership certificate Birth certificate
Adoption certificate
Divorce, dissolution or annulment papers

File

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 500 MB, Max. files: 8.

Disclosure Check Consent

DISCLOSURE CHECK CONSENT FORM The job for which you are applying involves substantial opportunity for access to children. It is therefore exempt from the Rehabilitation of Offenders Act 1974. If you are selected for interview you will be asked at interview if you have any criminal convictions and you will be given an opportunity to discuss the matter at this stage. Should you be offered the job, the employer is also entitled , under arrangements introduced for the protection of children, to check for the existence of and details of any criminal convictions or pending prosecutions you may have, even if they would otherwise be regarded as “spent” under this Act, and any cautions and bind-overs. This process is called disclosure. You will be asked to complete a separate disclosure application form which is forwarded to the Criminal Records Bureau for checking. Once complete they will send your employer details of any criminal record. As part of the disclosure process you will receive a copy of the completed check direct from the Criminal Records Bureau. A disclosure check will not be made without your consent, although you should be aware that refusal to give your consent could result in an appointment being withdrawn. The disclosure of a criminal record, or other information, will not debar you from appointment unless the employer considers that it makes you unsuitable for appointment. In making this decision the employer will consider the nature of the offence, how long ago, what age you were when it was committed and any other factors which may be relevant. Information revealed in the disclosure check will be kept in strict confidence and will be destroyed immediately once the recruitment process is completed. Please complete and sign below: • I have made an application for employment and I understand that this work is subject to a disclosure check. • By completing this form I consent to the transfer of my information to the Criminal Records Bureau for the purpose of a Disclosure Application. • I confirm that the information that I have provided in support of this application is complete and true and understand that knowingly to make a false statement for this purpose is a criminal offence.

I Consent

I consent to give Piers Meadows Recruitment permission carry out online DBS checks both annually or as required

I Consent

Signature(Required)

Date