Name *

First Name

Last Name

Phone

(###)

###

####

Please confirm if you have ever *

Note: Answering "Yes" to any of the above questions does not automatically disqualify you from consideration. However, it is essential for us to be aware of these details to make an informed decision. Select as many as apply.

Been disqualified, discredited, barred, or banned from any professional organisation, practice, or role.

Had a membership revoked by any professional body.

Been subject to any professional disciplinary actions including in a volunteer role.

Been involved in any court proceedings related to your professional conduct or otherwise.

Faced any criminal proceedings or have any spent or unspent convictions.

Encountered or been responsible for any other organisational, safeguarding, or therapeutic risks that we need to be aware of.

Have any pending disciplinary actions, revocations, bans, convictions, or court proceedings.

Had a County Court Judgment (CCJ) issued against you.

Been in any kind of debt or financial difficulty that may impact your professional responsibilities.

Other

None of the above

I hereby declare that the information provided is true and accurate to the best of my knowledge. I understand that providing false or deliberately misleading information may result in the rejection of my application or termination of my employment if discovered at a later date. I also understand that providing false or deliberately misleading information may mean I am subject to a disciplinary, formal complaint being lodged against me, revocation from my membership or in some cases, criminal proceedings and police involvement. *

I have read and agree to the declaration and confirm that the information is true and to the best of my knowledge