Form for

Thank you for applying to join Daisy-fields team. As part of the selection process, we should be grateful if you would complete this form fully in black ink or typescript and return it to the address specified within your application pack.

Employment Opportunities*

Personal Details

Emergency Contact Details

Equal Opportunities Monitoring

To ensure we are meeting our commitment to equality we need to know about the gender, ethnicity, religion/belief, disability, marital status and sexual orientation of people who apply to us, and whether they regard themselves as disabled. By completing this section you will help us to effectively monitor the recruitment and selection process.;

MaleFemaleI do not wish to answer

Cultural Ethnic Background


BritishIrishOther white (describe below)

Black or Black British

CaribbeanAfricanOther black (describe below)

Asian or Asian British

IndianPakistanBangladeshiOther Asian (describe below)

Dual Heritage

White and Black CaribbeanWhite and Black AfricanWhite and AsianOther Mixed (describe below)


ChineseOther (describe below)


Do not wish to answer

Religion and Belief *

BuddhistChristianHinduJewishMuslimSikhNo Religious BeliefsDo not wish to answerOther religion/Belief, Please describe:

Disability and Mental Health

The Equality Act 2010 defines a disabled person as someone who has a physical or mental impairment which has a substantial and adverse long-term effect on his or her ability to carry our normal day-to-day activities.


Marital Status *

SingleCivil partnershipWidowedDo not wish to answerMarriedSeparated/DivorcedPartnered

Sexual Orientation *

HeterosexualBisexualGay/LesbianDo not wish to answer

Transgender *

YesNoDo not wish to answer

Previous Experience: Employment / University / Organisation Details (if applicable)

Is your employer, university or organisation supporting you in this application to become a volunteer? *YesNo

Previous Employment (most recent first)

Please state all employment beginning from your first employment. Explain fully any gaps in employment or reasons for not working. IF NOT COMPLETED APPLICATION WILL BE RETURNED.

Previous Employment 1 *

Previous Employment 2

Previous Employment 3

Previous Employment 4

Previous Employment 5

Previous Employment 6

Previous Employment 7

Previous Employment 8

Previous Employment 9

Previous Employment 10

Background Information

Relationships: Canvassing may disqualify your application. Do you have a relationship (personal, business or professional) with an employee of the company or any member of its committees or working groups? *


Additional Information

All posts within Daisy-fieldz are exempt from the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Order 2001. You are required to declare any pending prosecutions or convictions you may have, even if they would otherwise be regarded as “spent” under the Act. You must also declare any cautions or bind-overs.

Have you ever been convicted or found guilty by a Court of any offence in any Country? Have you been put on probation, received a formal caution or been absolutely/conditionally discharged for any offence? Do you have any pending court action against you? If yes, please give full details and dates. If none, leave blank.

Safer Recruitment and Selection

As the post which you are applying for provides substantial direct / indirect access to vulnerable adults, your appointment will be subject to rigorous vetting processes including checks by the Criminal Records Bureau and other relevant bodies.





Immigration, Asylum and Nationality Act 2006


YesNoNot Applicable

If you cannot provide proof of permission to work in the UK we cannot accept your application as you are unable to work legally in the UK.

If you can provide proof of permission to work, please state the nature of your permission to work in the UK, any restrictions on the hours you are permitted to work and the expiry date of the permission.

We will require sight of the original documentation which confirms that you are permitted to work in the UK at the interview and offer verification stage, should you be successful. We may take copies of the document(s) and carry out checks to authenticate them


Please give names and addresses of TWO referees, not related to you, who are willing and able to provide up-to-date information on your qualifications, experience and skills. One of these MUST BE your current or most recent employer. If you have not previously been employed a referee related to relevant voluntary or community work or, if appropriate, your head teacher or lecturer/tutor from your last school or college or university. If you currently or have previously worked with young people or vulnerable adults, the other reference MUST BE from this source.



Data Protection Act 1998:

Daisy-fieldz will process the information provided on this form for the purpose of personnel administration, including pay and pensions. It will only be disclosed outside Daisy-Fieldz Company to organisations that are under contract to process data in these areas.

I declare that I am not on an Independent Safeguarding Authority List (formerly the Protection of Vulnerable Adults (PoVA) List, or the Protection of Children Act (PoCA) List, or List 99), or disqualified from working with vulnerable adults or children, or subject to sanctions imposed by a regulatory body, for example, the General Social Care Council, Nursing and Midwifery Council, etc. and have no convictions, cautions or bind-overs which are not detailed within the relevant sections of this application form.

I confirm that the information I have given is, to the best of my knowledge, true and correct and may be stored and used in accordance with Daisy-fieldz recruitment and selection procedures. I understand that or giving false information will disqualify my application, may be used in the detection and prevention of fraud or, if discovered after appointment, may be grounds for dismissal.