FOR OFFICE USE ONLY:

Recd/Ack
EO No:

CONFIDENTIAL - Application Form

The University is an Equal Opportunity Employer

Please complete this application form using Microsoft Word by typing in the shaded fields or writing legibly in black ink. Application
forms received after the closing date will not normally be considered. Do not enclose a curriculum vitae as it will not be used as part of
the shortlisting process. Applications for employment are treated with the utmost confidentiality, subject only to normal legal
requirements.

Position applied for: Reference No:

School/Department: Closing Date:

Personal Information
Title: Forename(s) (in full): Preferred Forename: Jessica

Surname/Family Name:

Address for Correspondence:

31 Windsor Crescent
Cookstown

Post Code:

Home Telephone Number: 028 867 65980

Mobile Phone Number: 07821771136
Email Address:

Date of Birth:

National Insurance No: JL 58 05 10c

Are you a national of an EU country? Yes No

If NO, please state your nationality:

Do you require a Work Permit to work in the United Yes No

Kingdom?

In accordance with the University's equal opportunities policy the University would like to ensure that candidates,
regardless of disability, can participate fully in the selection process. If you consider yourself to have, or to have had a
disability and require any specific arrangements to be put in place should you be invited for interview, please specify any
such arrangements.

Please specify the publication or website where you saw this post advertised: www.qub.ac.uk/jobs

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Education and Qualifications

Starting with the most recent, please give details of your education and training (certificates will be required if you are
recommended for appointment). Where insufficient space is provided, please expand the boxes or attach a separate
sheet.

School Education

From: To: Subject: Examinations Result: Date Awarded:

Taken:
2008 2009 ICT A LEVELS A 08/2009
History       A      
Geography       A      
2007 2008 ICT AS LEVELS A 08/2008
History       A      
Geography       A      
English       A      
Literature
2006 2007 ICT GCSEs A* 08/2007
French A*
RE A*
English A
English Lit A
Geography A
History A
Maths B
Double Award BB
Science

Further Education

From: To: Name of College/ Examinations Result: Date Awarded:

University/ Taken:
Course Provider:
2009 Present Queen's CSC1007 N/A N/A
University CSC1010
Belfast CSC1011

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Professional Qualifications and Memberships of Professional Bodies

Professional Date Qualification Date of Membership: Level of Membership:

Body/Institution: Achieved:
N/A

Training

Please provide details of any additional training course(s) undertaken.

From: To: Name of Training Course: Result: Date Awarded:

N/A

Employment History

Please provide details of all positions held since completing your full-time education, starting with your most recent
position. Please also give details of any gaps in paid employment, eg. voluntary work/caring responsibilities.

Name and Address of Employer/ Position held/ Main Duties of Post

Dates of Employment/
Reason for Leaving
SELB Cleaner
Cookstown High School
Coolnafranky Demense Working individually in a specific area.
Cookstown Carrying out general cleaning such as brushing and mopping.
Northern Ireland Using everyday chemicals to wash glass and toilets.
BT80 8PQ Using specialised machines in the floor scrubbing routine.

18/09/2006 to 18/09/09

Started university and working hours

didn't suit

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Employment History continued

Name and Address of Employer/ Position held/ Main Duties of Post

Dates of Employment/
Reason for Leaving

Present Wage/Salary: N/A Period of Notice Required: N/A

The University may seek evidence of salary prior to appointment.

4 REF:, EO No.:
Relevant Information

Please demonstrate, on this page only, by providing clear and unambiguous statements how your qualifications, skills and
experience meet the essential and, if appropriate, desirable criteria which are outlined in the Job Details.

I have studied ICT for four years at school and have continued to study in this field by undertaking a computer
science degree. I believe that this would meet the requirements given as I can make use of many computer
programs such as Word, Excel, Access, PowerPoint and a few others.

I believe this is a benefit as I am able to work with spreadsheets as well as databases as I have used all the
database features when I created my own for my ALevel studies.

By studying history and geography I learnt how to communicate my opinions and thoughts in a clear and easily
understood manner so that others could read with clarity what I had written and fully understand.

These subjects have also allowed me to develop my analytical mind meaning that I can study and interpret
many things and has encouraged the following of instructions. This has equipped me with the ability to
understand instructions easily and quickly which I believe would be a benefit.

Through my previous job as a cleaner I have become more organised and accustomed to a regular routine that
is to be followed. I believe this would help me as I would be able to follow a set routine created by the superiors
and follow it to a high standard.

I also believe that my work with special cleaning machinery and computers within my studies that I would be
able to work with specialised machinery quickly and with ease as I have had to in the past.

     
This job also meant that I was working in areas occupied by teachers and senior staff members which meant
that there was the possibility of overhearing confidential information. I was trusted to keep this information
secret and not to discuss it with anyone showing that I am trustworthy.

     
Within my work experience I was in the position of teaching staff meaning that information again could be
shared and I was obliged to keep anything heard in confidence which I believe is needed when working in an
environment with many jobs and students.

I was obliged to take part in presentations within my studies and therefore I believe that I would be able to
communicate effeciently and clearly any information, which I believe is important when dealing with the public
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

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Referees
Please give the name and contact details of three persons, not relatives, both professional and personal, who may be contacted for
references in support of your application. One of these persons should be your most recent/present employer or course tutor/teacher if
currently a student. If your referees knew you by a different surname, please specify here:

Name: Mr R Balmer Position: Senior Teacher

Address: Cookstown High School

Coolnafranky Demense
Cookstown
Co.Tyrone
Post Code: BT80 8PQ

Telephone No. : 028 867 63632/63620

Email:

Do we have permission to contact this referee? Yes No

Name: Mrs Moira Allen Position: Cleaning Supervisor

Address: 32 Stewart Avenue

Cookstown

Post Code:

Telephone No. : 028 867 63961

Email:

Do we have permission to contact this referee? Yes No

Name: Mrs A Sloan Position: Principal

Address: Cookstown High School

Coolnafranky Demense
Cookstown
Co Tyrone
Post Code: BT80 8PQ

Telephone No. : 028 867 63632/63620

Email:

Do we have permission to contact this referee? Yes No

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Confidential Disclosure of Criminal Convictions

Information about criminal convictions is requested to assist the selection process.

Below you are required to declare any previous criminal convictions. This information will be treated in a confidential manner and will
be considered as part of the shortlisting for the position.

Failure to provide correct information may affect your application. If an applicant is found to have withheld information about criminal
convictions it may lead to dismissal.

Please answer the following questions.

Have you ever been convicted of a criminal offence including cautions/bindovers? Yes No

(Not including those that would be considered 'spent' under the terms of the Rehabilitation of Offenders Order (NI) 1978.)

DATE CONVICTION TYPE OF SENTENCE

We would encourage you to provide a statement of disclosure below providing any further information you feel may be relevant such
as the particular circumstances leading to the offence and why an employer should disregard the conviction.

Declaration
I certify that, to the best of my knowledge, the information which I have given is true and complete. I accept that, if I have supplied any
false statements or have withheld any relevant information, any offer of employment can be withdrawn or an accepted appointment can
be cancelled. In addition to the referees quoted, I understand that the University reserves the right to make such further enquiries on my
candidature as it deems appropriate including any unspent civil or criminal convictions.

To return your Application Form and EO-Form on-

line please do the following: Signature: Jessica Rollins
1. Ensure both documents are saved on your pc
2. Visit www.qub.ac.uk/jobs and submit your If you are returning this form via e-mail, please type your name above in place
application against the relevant job. of your handwritten signature.

Alternatively post your application to

The Director of Human Resources,
The Personnel Department, Date: 15/012/2009
Queen's University Belfast,
Northern Ireland, BT7 1NN
8 REF:, EO No.:
 (Tel: 028 9097 3044, Fax: 028 9097 1040).

Position applied for: Reference No:

School/Department:

Name:

INFORMATION ABOUT AND CONSENT TO THE PROTECTION OF CHILDREN (NI)

SERVICE CHECK BY APPLICANTS FOR POSTS INVOLVING WORK WITH CHILDREN

You have applied for a child care post which is a regulated position. Before appointing anyone to such a post, it is our policy to ask for a
Protection of Children and Vulnerable Adults (NI) Service (POCVA (NI)) check to be carried out by the Department of Health, Social
Services and Public Safety (DHSSPS). This check is to make sure that individuals who might be a risk to children and vulnerable adults
are not appointed.

The check will tell us if you have a criminal record, or if your name is included on the DHSSPS Disqualification from Working with Children
List or included on the DE List. Any information received will be treated confidentially and we will talk to you about it before a final decision
is reached. After the decision is made, the information will be destroyed. (Employment/Nursing Agencies and Employment Businesses will
retain this information for 12 months).

A check will only be carried out if you are considered to be the preferred candidate and are being offered an appointment. You must tell us
now if you have ever been convicted of a criminal offence or cautioned by the police or bound over. You must tell us about all offences,
even minor ones such as motoring offences, and 'spent' convictions, that is, things which happened a long time ago. If you leave anything
out, it may affect your application.

Please complete the section below and ensure this page is returned with your application. If you do not consent to the check we will not
accept your application.

CONSENT TO POC (NI) CHECK

1. Do you have any prosecutions pending Yes No (if yes please give details)

N/A

2. Have you ever been convicted at a court or cautioned by the police for any offence? Yes No

If yes, please list below details of all convictions, cautions or bind-over orders. Give as much information as you can, including, if possible,
the offence, the approximate date of the court hearing and the court which dealt with the matter.

N/A

3. Please indicate any previous surname:

4. Please supply all addresses within the last 5 years including dates:

31 Windsor Crescent
Cookstown
BT80 8EZ

5. If you have EVER lived elsewhere in the UK (Northern Ireland, England, Scotland, Wales) or the Republic of Ireland please give details:

N/A
     
     

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I understand that a POC (NI) Service check must be carried out before an offer of appointment can be confirmed. This has been explained
to me and I am aware that spent convictions may be disclosed. I declare that the information I have given is accurate and I consent to the
check being made.

You MUST tick this box to confirm that you have read and agree to the above declaration
(Queen's University Belfast will not accept your application if you have not ticked this box)

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