Governor with digital experience - application form

Name*

Prefix First Last

Address*

Street Address Address Line 2 City County Postcode

Home Telephone

Mobile*

Email Address*

Supporting Statement*

CV Upload*

Max. file size: 1 GB.

Have you ever been convicted of a criminal offence*

Yes
No

All appropriate posts at St Richard’s Hospice are subject to DBS disclosure.

Please provide three professional references

Reference One Name*

First Last

Reference One Address*

Street Address Address Line 2 City County Postcode

Reference One Phone number*

Reference One Email*

Reference One's relationship to you*

Reference Two Name*

First Last

Reference Two Address*

Street Address Address Line 2 City County Postcode

Reference Two Phone number*

Reference Two Email*

Reference Two's relationship to you*

Reference Three Name*

First Last

Reference Three Address*

Street Address Address Line 2 City County Postcode

Reference Three Phone number*

Reference Three Email*

Reference Three's relationship to you*

Automatic Disqualification Declaration*

I declare that: I am not disqualified from acting as a trustee; and I will inform the trustees promptly if, after the date of this declaration, one or more of the disqualification reasons applies to me

Charities must satisfy themselves that individuals who hold (or are applying for) a trustee position will not be disqualified from holding that position. Please see the guidance here: www.gov.uk/guidance/automatic-disqualification-rule-changes-guidance-for-charities

Please read*

I confirm that I have read the privacy statement and terms & conditions of St. Richard’s Hospice and consent to the use of my personal data as set out as stated.

Governor with digital experience – application form

Governor Application