AGENCY OPERATIVE APPLICATION FORM

Please use black ink - ALL SECTIONS MUST BE COMPLETED and BLUE SIGNATORY
SECTIONS SIGNED

PERSONAL INFORMATION
Forenames: Sachitha Madushani Surname:Kossinna Vidanalage

Maiden/other name:NA Date of Birth:28/03/1992

Address:
610,Westgate House, Harlow ,Essex

Proof of Identity provided? (Passport, Driving Licence Card(both sides, other photo ID)
□ YES
How long have you lived at the above address? (If Proof of address x 2 provided? (within last 3 months bank
less than 5 years please provide list of previous address and statement/UtilityBill/Driving Licence (both sides), C. Tax)
dates) □ YES
1 year and one month
Previously:37,Kasungama,Matiyagane,Sri Lanka

Use a separate sheet if needed

Home Phone No:NA Mobile Telephone No: 07877632345

Email: kvmsachithra@gmail.com

National Insurance No:TK178993B Proof of Nat. Ins provided? (Payslip, NI Card, HMRC letter)
□ YES
Nationality:Sri Lankan Proof of Permission to Work in UK provided?
(Passport/Visa/BRP(both sides), Birth Certificate)
□ YES
P45 provided? Current DBS provided?
□ YES □ NO □ YES □ NO
QTS Number? Update Service Registration?
□ YES □ NO □ YES □ NO
Permission given to access DBS / Update Service? □ YES □ NO
Medical Questionnaire completed? Safeguarding Acknowledgement/Childcare
□ YES □ NO Disqualification Consent Form signed?
□ YES □ NO
PAY INFORMATION
Names of Bank:Lloyds bank Account holder:SM Kossinna Vidanalage
Sort Code:309389 Account No:53539268
EMERGENCY CONTACT
Name:Srinath Nelumdeniya Relationship:Husband
Address:610,Westgate house,harlow
Telephone (home):NA Telephone (work):NA
Telephone (mobile):07723138663 Email:srinthdf@gmail.com
QUALIFICATIONS/TRAINING
State appropriate Qualifications and Training: (most recent first)

After my A-levels, I completed Diploma in English at University of Wayamba in Sri Lanka as learning English as a second
language is more imperative. Throughout the course I learned to communicate fluently with others which is really helpful for me now.
Moreover, it made a thirst to learn more about the language in order to become an English Teacher. Therefore, after completing the
Diploma in English I started Higher National English Diploma at Advanced Technological Institute which paved the way to begin my
journey as a reputed English Teacher. This programme covers of subjects including Literature, masterpieces to cover every era in four
semesters, Education principles, Education measurements, Child psychology, computer literacy and so on. The duration of the entire
programme was two and half years including six months internship in a government school.
I found this as a great opportunity to explore more about my skills as a teacher in a school. This role allowed me to work
closely with the children and support them in their lessons. This experience was gratifying, and I enjoyed helping the children learn
and solve problems. I found myself excited to get to work and see the children and they seemed just as excited to see me.
Furthermore, I was able to make an interest of learning for the students through various activities: language games, competitions,
making creative dramas, singing songs, lessons through activities and based on stories. Apart from that, I handled two special
programmes to upgrade the English literacy among students. Also, I had the chance to cover the primary grades when the teacher was
absent and to help and cover the Special needs classrooms in the school. Although I only spent six months at the school, I still formed
a friendship with lots of the children and learned more essential skills for working with young children such as safeguarding and
following a curriculum.
I also have the work experience of Senior English Lecture at Westgate College for six years. Though I started my journey
there as an English Teacher with my dedication and hard working with my skills I was promoted to the Senior position. I managed a
team of three supporting teachers and more than hundreds of students to qualify their entitled qualifications successfully. As detailed
in my CV, I directed my duties and responsibilities academically and professionally which I was rewarded by my Head Teacher.
After arriving UK, I got the opportunity to work at Harlow College as a Leaning Support Assistance. This influenced me to
learn British school leaning environment exposing to plenty of staff members and students apart from assisting students to reach their
potential. I got positive feedbacks from the teachers for the way I helped them and allow me to have more responsibilities through the
period. I was intrigued by what influences students to act the way they did and have a particular fascination with how children develop
in a society. Becoming a teacher allows me to make a difference in children’s lives through my skills and experience in an exciting field
that I am passionate about. Thank You.

Use a separate sheet if needed

POST
State post applying for:
Teaching Assistant
REFERENCES
Please provide 3 referees – : Two must be a manager/head teacher from your most recent employers.

Name: Sabina Miah

Company: Specsavers
Address: 10-12 Broad Walk, Harlow
Position: Dispensing Advisor
Contact Telephone: 07459229938
Contact Email: sabina.miah@specsavers.com
Dates known from and to:03/2023- 12/2024
Can we contact them immediately? □ YES □ NO

Name: Shani Vindya Bandara

Company: Westgate College
Address: Round circular road, Kurunegala, Sri Lanka
Position: Nursing coordinator/Assistant Manager
Contact Telephone: +94 773904420
Contact Email: shanivindya@gmail.com
Dates known from and to:05/2021 – 01/2024
Can we contact them immediately? □ YES □ NO

Name: Manesh Jayasooriya

Company: Westgate College
Address: Round circular road, Kurunegala, Sri Lanka
Position: Head Teacher
Contact Telephone: +9477-7701566
Contact Email: visa@westgate.edu.lk
Dates known from and to:03/2020- 11/2022
Can we contact them immediately? □ YES □ NO

REFERENCE CONSENT

I hereby give my consent to Harton Search Ltd to contact the referees given above

Name: Sachithra Madushani

Signature: Sachi Date: 05/01/2024
REHABILITATION OF OFFENDERS ACT:
As of 29 May 2013 you are no longer required to disclose information about any information about any ‘filtered’
offences. Additional guidance in can be provided which sets out the filtering rules for criminal record check
certificates. You are not required to disclose on any part of this form any convictions or cautions that have been
‘filtered’. Guidance and criteria on the filtering of these cautions and convictions can be found on the Disclosure and
Barring Service website.
Subject to the filtering rules failure to declare a conviction that you must disclose mat require us to exclude you from
our register or terminate and assignment if the offence is not declared but later comes to light.

1: Do you have any unspent* Criminal Convictions?

 □ YES □ NO
If yes, please list your criminal convictions and their dates on a separate sheet subject to the filtering rules. The
information you give will be treated in confidence and only taken into account where, in the reasonable opinion of
Harton Search Limited, the offence is relevant to the post for which you are applying.

*A conviction will become spent after a ‘rehabilitation period’. A list of these periods can be provided if needed.

Not applicable

2: As an exception to the Rehabilitation of Offenders Act 1974, for certain roles and professions you are required to
disclose all spent and unspent convictions. The DBS checks: eligibility guidance (attached) explains who is eligible
for DBS checks but anyone doing such work must disclose spent and unspent convictions (subject to the filtering
rules). If this is relevant to work that you are seeking please list all criminal convictions (spent and unspent) and their
dates below, subject to the filtering rules If this section does not apply to you please write ‘not applicable’ :

As per 221 KCSIE Candidates may be subject to an online search.

Teachers will be subject to a Prohibition Check as per 232 of KCSIE.
EQUAL OPPORTUNITIES
Harton Search Ltd is committed to a policy of equal opportunities for all employees, workers and applicants
and shall adhere to such a policy at all times and will review on an on-going basis all aspects of
recruitment to avoid unlawful or undesirable discrimination.

H a r t o n S e a r c h L t d will treat everyone equally irrespective of sex, sexual orientation, gender

reassignment, marital or civil partnership status, age, disability, colour, race, nationality, ethnic or national
origin, religion or belief, political beliefs or membership, pregnancy and maternity or non-membership of a
Trade Union or spent convictions, and places an obligation upon all staff to respect and act in accordance with
the policy.

Harton Search Ltd is committed to providing training for all its’ staff in equal opportunities
practice.

As part of our commitment to equal opportunities, we need to obtain information about the ethnic origins,
age, sexual orientation, religion and belief, disability, marriage or civil partnership and sex of our employees and
job applicants.

This information enables us to examine, by ethnic origin and sex, the distribution of employees across the
organisation, and the success rate of candidates for jobs, training, transfer and promotion, according to the type
of job.

We hope that employees and job applicants will co-operate by completing the information overleaf, which
will help us to assess whether the distribution of staff and the success rate of applicants is fair and equal.

Any information provided will be kept confidential and will only be used for monitoring diversity and equality of
opportunity.

The following questions are optional. Information you do provide will be kept confidential.
Do you have a disability?
The Equality Act 2010 defines a person as having a disability if he/she has a physical or mental impairment,
and that impairment has a substantial and long-term adverse effect on his/her ability to carry out normal day-to-
day activities

□ YES □ NO If yes, what support you may need:

Age  16 – 20  36 – 50

 21 – 35  50 +
Sex  Male  Female  Other:
Sexual Orientation  Bisexual  Heterosexual Other:

 Gay Man  Gay Woman/ Lesbian

Marital status  Married  Single  Civil Partnership
Religion or belief  Christian (all denominations)  Humanist
 Buddhist
 Hindu  Atheist
 Jewish
 Muslim  other Belief, state:
 Sikh
 Ethnic Origin White Mixed/multiple ethnic groups
 White – English, Welsh,  White and Black Caribbean
Scottish, Northern Irish, British  White and Black African
 White – Irish  White and Asian
 White – Gypsy or Irish  Any other Mixed/multiple
Traveller ethnic background, state:
 White – Any other White
background, state: Black/African/Caribbean/Black
Asian / Asian British British
 Indian  African
 Pakistani  Caribbean
 Bangladeshi  Any other
 Chinese Black/African/Caribbean
 Any other Asian origin, state: background, state:
Other ethnic group
 Arab
 Any other ethnic group, state:

DATA PROTECTION
The information that you provide on this form and on any CV given will be used by Harton Search Limited to provide
you with 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 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 ways permitted or required by law.
AGENCY OPERATIVE DECLARATION
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 my data being audited by Harton Search Ltd and/or 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 Harton
Search Ltd will be entitled either to charge the client an introduction/transfer fee, or to agree to 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).

Name Signature Date

Sachi 05/01/2024
Sachithra Madushani