Part B: References
Please give details of two people who know you well, but to whom you are not related, covering
your employment during the last five years if possible. If you are a student, one referee should
be a teacher.
Reference One
Title First Name Surname
Address
Home number Mobile number
Email address
Reference Two
Title First Name Surname
Address
Home number Mobile number
Email address
Part C: Disclosure of Criminal Convictions
You are required to disclose all unspent convictions, reprimands, bind overs and cautions and
any pending prosecutions although this does not automatically mean you will not be selected
as a volunteer. If no convictions please enter ‘none’.
Convictions (Offence)
Sentence Date
Pending Prosecutions
Alleged Offence
Appearance
Date
Some activities will require additional screening in the form of a DBS disclosure for working
with children and vulnerable adults. The role description will tell you if this is required.
Part D: Other Information
Do you currently have the legal right to volunteer in the UK? Yes No
Do you need any extra support or assistance to volunteer? Yes No
Will you be putting your volunteering hours towards any award
schemes?
Yes No
If yes, which scheme?
Part F: Declaration
I certify that, to the best of my knowledge, the information I have provided is true and I
understand that any false information or failure to disclose criminal convictions may result in
the termination of volunteer arrangements with Southend Library and Museum Services. I give
consent for personal details to be held on the Volunteer Database in accordance with the Data
Protection Act 1998.
Signature Date
