Do not leave any box blank – please write – n/a if not applicable (such as driving licence number etc).


First names (including middle names):



Date of Birth:

Passport No:

Address & Postcode:

Email Address:

NI Number:

DBS Number:

Date of Issue:

Mobile Number:

Home Number:

DfE/IFL Registered Yes   No

Teacher Reference Number/IFL Number (if applicable):

Closest Station:

Do you have access to a car? Yes   No

Driving Licence Number (if applicable):

Emergency Contact Name:

Emergency Contact Number:

What is their relation to you:

What is your expected daily rate (Before Tax/ NI)?

Is your DBS registered online – (you will have paid £13 for the update service within the last 12 months if so) Yes   No

Is your DBS

Child checked only Yes   No

Child and adult checked only Yes   No

How did you hear about Active Recruitment Ltd?:

Do you have any holidays booked or are unavailable on certain days which you know about in advance?:

Do you agree to call Active Recruitment on 0208 508 7108 by 715am, or the previous day if you are unable to go to work due to sickness or any other reason? Yes   No

Do you agree to call Active Recruitment on 0208 508 7108 if you leave the school at any time after arrival but before the end of the day? If you cannot make the call yourself you must ask another person to inform us by phone immediately. Yes   No

Active Recruitment Ltd will not refund any expenses incurred by you in the course of your work unless you ask us for permission first before buying items such as textbooks, classroom items, food for school cookery, etc. It is essential that you both seek permission first and keep receipts. This request must be by email. Please tick to confirm that you agree with this. Yes   No


Please select if you have a UK Passport Yes   No

Biometric ID Card/ VISA Number if non EU (please write EU if from the European Union):

Have you completed overseas Police Checks for the last 5 years? Yes   No

Do you have the right to work in the UK: Yes   No

Visa Type:

Visa Expiry Date:

In line with UKBA guidance on the prevention of illegal working we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by ACTIVE RECRUITMENT LTD for temporary work


References will only be taken up with your knowledge and agreement.
List present or most recent position first


Full name:

Dates you knew this referee from:

Dates you knew this referee to:

Their work email address:

Your role/ job title (i.e. Teacher/ TA/ Student):

Their role/ job title (i.e. SLT/ HR/ Tutor):

Their place of work:

Reason for Leaving:


Can we apply straight away for a reference Yes   No


Full name:

Dates you knew this referee from:

Dates you knew this referee to:

Their work email address:

Your role/ job title (i.e. Teacher/ TA/ Student):

Their role/ job title (i.e. SLT/ HR/ Tutor):

Their place of work:

Reason for Leaving:


Can we apply straight away for a reference Yes   No

Preferred subject to teach:

Preferred year group to teach:

Type of work:

How many days off sick have you required in the past year: 0-5       More than 5

Have you included a minimum of one work email for your references? Yes   No

Have you asked permission first in the last 12 months from this person for a reference? Yes   No

Please confirm which of the following you have experience of: Makaton
P-levels or Milestones
Hand on hand signing for deaf blind learners
British Sign Language
Team Teach or any other restraint training
Personal Care
Peg Feeding
Manual Handling
Read write Inc
Ruth Miskin


The following questions on health and disability are asked in order to find out your needs in terms of reasonable adjustments to access our recruitment service and to find out your needs in order to perform the job or position sought.

1.1. Do you have any health issues or a disability relevant which may make it difficult for you to carry out functions which are essential for the role you seek?

Yes   No

If yes, please specify

Do you consider yourself medically fit for teaching in the UK? Yes   No

I declare that all the answers to the above questions are true and complete to the best of my knowledge. I understand that any false statement or material omissions may lead to my removal from the register and/or refusal or any offer of work. Yes No

Assignments will involve you in close contact with pupils under the age of 18 or with students with learning difficulties or disabilities; your registration with ACTIVE RECRUITMENT LTD is therefore exempt from the provisions of the Rehabilitation of Offenders Act 1974 and its supporting regulations. Consequently you are NOT entitled to withhold information about convictions which for other purposes are “spent” under the Act. ACTIVE RECRUITMENT LTD will check the information given in this section with the relevant authorities. You will be required to apply for an enhanced disclosure level of police check through DBS (Disclosure & Barring Services).

Have you been convicted of a criminal offence other than a road traffic offence not involving injury to a 3rd Party, or a sentence of imprisonment? Yes No

If yes, please provide details below







Disqualification by Association

All employees are required to provide relevant information about a person who lives in the same household as them, who may have influence over the employee working with children and who may therefore pose a risk to children i.e. “by association”.

You are therefore required to disclose:

  • Details of any order, determination, conviction, or other ground for disqualification from registration under the Childcare (Disqualification) Regulations 2009. You are required to declare whether anyone living in your household is disqualified from working with children under the childcare Act 2006. This covers the following offences:
             - offences against a child
             - against an adult (e.g. rape, murder indecent assault, actual bodily harm etc.)
  • The date of the order, determination or conviction, or the date when the other ground for disqualification arose;
  • Information about the body or court which made the order, determination or conviction, and the sentence (if any) imposed;
  • and A certified copy of the relevant order (in relation to an order or conviction).

Has anyone living in your household been barred from working with children by the DBS? Yes No

Has anyone living in your household been disqualified from working with children under the childcare Act 2006? Yes No

Employees living in a shared household

To the best of your knowledge, is anyone living at your address subject to the above? Yes No

If you have answered YES to any of the above, please provide further information below (you may provide an additional information sheet if necessary):

Any relevant information will be passed to OFSTED to make a decision as to whether the offence would lead to disqualification by association and you will be notified of their decision accordingly.


I confirm that the information I have declared above is correct and understand that I have duty to inform the Head teacher should any of this information change at any time during my employment with the school. Yes No

Appendix A (to be read by all new employees)

A check as to the existence and content of any relevant criminal record will be requested from the Disclosure and Barring Service after a person has been selected for appointment. Refusal to agree to a check being made could disqualify you from being considered for the appointment.

Under the Rehabilitation of Offenders Act 1974, you have the right not to disclose details of ‘spent’ convictions. However, for certain jobs, employers are allowed to ask about these offences. The Rehabilitation of Offenders Act 1974 (Exception Amendment) Order 1986 sets out details of all jobs to which this applies and the job you have applied for is included in the list. The amendments  to the Exceptions Order 1975 (2013) provide that certain spent convictions and cautions are 'protected' and are not subject to disclosure to employers, and cannot be taken into account.


The filtering rules (which remove certain old and minor convictions and cautions, reprimands and warnings from a DBS Certificate) were developed by the Home Office and the Ministry of Justice and introduced with new legislation:
The legislation is:

  • Police Act 1997 (Criminal Record Certificates: Relevant Matters) (Amendment) (England and Wales) Order 2013
  • Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013

The Filtering Rules.

For those 18 or over at the time of the offence:
An adult conviction will be removed from a DBS Certificate if,

  • 11 years have elapsed since the date of conviction; and
  • it is the person’s only offence, and
  • It did not result in a custodial sentence.

Even then, it will only be removed if it does not appear on the range of offences which will never be removed from a certificate, which include serious sexua l and violent offences. (see Exceptions to the Rules). If a person has more than one offence, then details of all their convictions will always be included.

An adult caution will be removed after six years have elapsed since the date of the caution – and if it does not appear on the list of offences relevant to safeguarding.

For those under 18 at the time of the offence:
For convictions, the same rules apply as for adult convictions, except that the elapsed time period is five and a half years.

For cautions, the same rules apply as for adult cautions, except that the elapsed time period is two years.

Exceptions to the Rules
Some offences will never be removed from a DBS Certificate. These include the most serious sexual and violent offences. You can view this specified list of offences at:
Further information is also available from:-
If you are unable to access the internet please contact the school who will be able to send this information to you direct.

You must provide details of any relevant criminal convictions that you may have. The disclosure of a criminal record may not necessarily prevent you from being appointed. The nature of the offence, how long ago it took place, your age at the time and any other relevant factors may be considered when a decision is made. Please note that some convictions are never considered ‘spent’ under the terms of the Act.


Have you ever been the subject of professional misconduct proceedings or suspensions from an employer, or such pending or threatened against you either in the UK or abroad.

If yes please give details attached to this application Yes No


The information you provide will be checked. If you are found to have provided false information your application will be terminated and you will be offered no assignments through ACTIVE RECRUITMENT LTD. Further action may be taken.

I declare that all the information I have provided is accurate, complete and true. Yes No


I have carefully read the Policy Statements published by and the Terms and Conditions and agree to be bound by them. Yes No


The information that you provide on this form and on any CV given will be used by ACTIVE RECRUITMENT LTD to provide you work finding services. In providing this service to you, you consent to your personal data being included on a computerised database and consent to us transferring your personal details to our clients.

We may check the information collected, with third parties or with other information held by us.

We may also use or pass to certain third parties information to prevent or detect crime, to protect public funds, or in other way permitted or required by law.


I hereby confirm that the information given is true and correct. I consent to my personal data and CV being forwarded to clients. I consent to references being passed onto potential employers.

If, during the course of a temporary assignment, the Client wishes to employ me direct, I acknowledge that ACTIVE RECRUITMENT LTD will be entitled either to charge the client an introduction/transfer fee, or to agree an extension of the hiring period with the Client (after which I may be employed by the Client without further charge being applicable to the Client). Yes No


Active Recruitment LTD operates a Refer a Friend Scheme. If you are happy to recommend our services then once your referral completes 30 days work for Active Recruitment you will be entitled to a bonus.

If you would like to recommend another Teacher, School support worker, TA, Nursery Nurse etc please fill in the box below and we will contact them.

Do you want to recommend a colleague or friend and receive up to £300? Yes      No


Contact No:

Email Address:

Subject/Year Group specialism:

Your application will be reviewed by the Active team who will contact you shortly. If you did not attach any required item you can still do so to Many thanks for your time.