Application Form

Role Title Community Survey Facilitator Reports to Field Co-ordinator

Section 1 Last Name: Address:

Contact details First Name:

Postcode:

E-mail:

Telephone No:

Section 2

Availability

Are you available to take part in a one-day training event on 26 January 2012? Yes What are you currently doing? Unemployed/ on benefits In full time work In part time work In education/ training Retired No

Are you willing to work outdoors? Yes No

Are you willing to travel around Maybole and work independently? Yes No

Section 3

Personal Statement

Please use this section to tell us about why you are interested in taking on the role and what experience, interests, and skills that you might bring to the role.

Section 4

References

Please give the names and addresses of up two people that would be willing to provide a reference for your character and reliability. Reference 1 Name: Position (job title): Relationship: Organisation: Address: Postcode Telephone No: E-mail: Telephone No: E-mail: Name: Position (job title): Relationship: Organisation: Address: Reference 2 Postcode

Section 5 Monitoring Information To help us ensure that our Equal Opportunities Policy is fully and fairly implemented (and for no other reason) please COMPLETE THIS SECTION OF THE FORM. Gender Male Disability Disability is defined as physical or mental impairment, which has a substantial and long term adverse effect on a persons ability to carry out normal day to day activities. 3 Female

Do you consider yourself disabled? If yes, please give details:

Yes

No

Age Group 16-25 46-55 Over 70 26-35 56-65 36-45 66-70

RETURNING THIS FORM By Post: Social Value Lab Third Floor 8 Nelson Mandela Place Glasgow G2 1BT By E-Mail: jonathan@socialvaluelab.org.uk Enquiries: Contact Jonathan Coburn 0141 352 7419