Personal Details
Surname Forenames Address Home no Mobile no Email ISA no ………………………………….. National Ins no. …………………….....................
Have you been a Charity Trustee before? If so, please list details:
Working in the UK
Are you eligible to work in the UK/EEA? YES / NO Do you require further leave to remain in the UK? YES / NO
References	Please give the names and addresses of two referees, at least one whom should be someone who has experience of you in a professional context.
1. 2. Position held: Position held: Relationship: Relationship: Telephone no. Telephone no Email Address…………………………………….. Email Address……………………………………..
Reason for your Application
Please state briefly why you are interested in applying for the role of a Trustee with AUKH.
Disability	(we are using the word “disability” to include people with obvious disabilities and those with invisible disabilities or persistent health problems)
Have you a disability which requires the provision of specific facilities at interview? If so, is there anything we could do to assist you? Please give details. ……………………………………………………………………………………………………………………………
Additional Information
Please state any public service / duties
Are you to your knowledge, related or have a close personal relationship to any executive member or employee of Age UK Hillingdon? If so please give details?
Supplementary Information
Please list the personal qualities, skills, experience and knowledge that you think would make you a good charity Trustee. Remember to include details of relevant experience and knowledge gained inside and outside of paid employment. Please continue on additional sheets if necessary.
Rehabilitation of Offenders Act 1974
The role of Trustee will have access to children or vulnerable adults or their records; we will require an enhanced disclosure from the Criminal Records Bureau and need to have information from you regarding any previous, existing or pending convictions or cautions. You are not entitled to withhold information even if your conviction, normally be considered ‘spent’. Have you ever been cautioned or convicted or a criminal offence? YES / NO Have you ever been disqualified from working with children or vulnerable adults? YES / NO If you do not disclose any criminal convictions or caution, including those ‘spent’, it could result in withdrawal of the offer or dismissal from your role.
Checklist for eligibility to be a Trustee
I have never been bankrupt nor made a composition with creditors
I have never been convicted of any offence involving dishonesty or deception
I have never disqualified from being a company director
I have not previously been removed from office of charity trustee on the grounds of misconduct or mismanagement
Signature
I declare that the information I have given is true and correct. Canvassing will disqualify your application. Signature of applicant ………………………………….……... Date…………………………………
Please return this form to: HR, Age UK Hillingdon, 2 Chapel Court, 126 Church Road, Hayes UB3 2LW or e-mail volunteering@ageukhillingdon.org.uk