Self Declaration Form

The Protection of Vulnerable Groups (Scotland) Act 2007

Private & Confidential

The post that you have applied for is for regulated work with children, protected adults or both. You are therefore required to disclose all convictions (spent and unspent), cautions, and any relevant non-conviction information.

Please give details regarding any convictions and cautions under the heading in Section 1.

Please give details of any relevant non-conviction information in Section 2.

Please ensure you enter your name at the declaration in Section 3. If you have nothing to declare on this form, please still return this form with your name and date with your application.

If you wish to discuss the form in confidence, please contact Elaine Brown, Human Resources Officer on 0131 220 0130 or by email to hr@apexscotland.org.uk.

Should you be appointed for the position applied for you will also be asked to complete a PVG Scheme record disclosure.

Post name
Reference
Name*
Email*
Section 1
Convictions and cautions
a) Please give the date and details of any conviction(s), the sentence that you received and the court where your case was heard.
b) Please give details of the reasons and circumstances that lead to your offence(s).
c) Please give details of how you completed the sentence imposed.
For example did you pay your fine as required, what conditions were attached to your probation/community service/supervised attendance order, did you comply with the requirements of your order/custodial sentence, etc.
d) Have any organisations supported you to work through any of the above issues?
e) What have you learned from the experience?
Section 2
Non-conviction relevant information
Investigation by police, involvement with Social Services, etc.
Section 3
Declaration
By returning this form, I certify that all information contained in this form is true and correct to the best of my knowledge and realise that false information or omissions may lead to dismissal or withdrawal of any offer of employment/volunteering.
Signature
Date
DD slash MM slash YYYY
NOTE: The information given in this form will be treated in the strictest confidence.
Email
This field is for validation purposes and should be left unchanged.

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a positive future

a positive future

Self Declaration Form

The Protection of Vulnerable Groups (Scotland) Act 2007

Private & Confidential

Section 1

Section 2

Section 3

Declaration

Contact details

Apex Scotland is a company limited by guarantee. Registered in Scotland No. SC126427. Registered as a Scottish Charity, Scottish Charity No. SC023879.

Apex service user

Apex service user

Tony, Apex service user

James, Apex service user

Gary, Apex client