DPULO Ambassador application form

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Disabled People’s User-Led Organisations (DPULOs) play a significant role in promoting the role and value of disabled people in their local community. The Strengthening DPULOs Programme was launched in July 2011 to provide a range of practical and financial support to DPULOs to support them to be strong and sustainable.

I am recruiting additional Ambassadors to further extend the Strengthening DPULOs Programme.

For further information, please visit: http://odi.dwp.gov.uk/odi-projects/user-led-organisations/ambassadors-application.php

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DPULO Ambassador application form

  1. 1. Application FormAmbassador to Office for Disability Issues promoting the roleand value of disabled people in the local community based inNW England, Scotland and WalesThis application form is separated into 8 sections (17 pages, including thiscover page). Please read each page carefully and ensure every question iscompleted.If you are handwriting your application form, please make sure your writing islegible. Please use black ink as this photocopies best.We are keen to make reasonable adjustments for applicants. If you would liketo use another format for your application, please contact us.Applications should be sent to: Audrey Daft, Ground Floor, Caxton House,Tothill Street, London SW1H 9NA. This can either be by e-mail or by post.Emailed applications should be sent to: Audrey.daft@DWP.GSI.GOV.UKThe closing date for applications is 8th June 2012 at 10am.Late applications will not be considered.There will not be a guaranteed interview for disabled people who do not meetthe minimum criteria. As we are expecting a lot of interest in these posts weexpect the calibre of applications to be very high.Can you tell me where you heard about this role?Disability Now Y/NGuardian/Times Newspaper Y/NOn the Office for Disability Issues Website Y/NTwitter/Facebook Y/NOther (please give details) 1
  2. 2. Section 1: Personal DetailsRole Reference Number:Title (Mr/Mrs/Miss/Ms/Other (please specify):Name:Home Address:Home Telephone:Mobile Telephone:E-mail address:Please add any other contact details (if applicable) and state your preferredmeans of contact e.g. telephone, email etc:Please list any dates when you will be unavailable between Monday 2nd Julyand Monday 9th July 2012.I have read the definition of a disabled person in the Candidate Informationpack and consider that I am a disabled person for the purpose of thisapplication.Please indicate as appropriate:YesNoThere will not be a guaranteed interview for disabled people who do not meetthe minimum criteria. As we are expecting a lot of interest in these posts weexpect the calibre of applications to be very high. 2
  3. 3. Section 2: Knowledge and ExperiencePlease respond to each of the criteria numbered 1-8 below. Please provideexamples of your knowledge and experience and the outcomes you haveachieved to demonstrate your suitability. Please limit your examples for eachcriterion to 400 words. The boxes will expand as you type.If you are writing your application form, you may continue on additionalsheets if required.Criteria1) Experience of working within local communities to increase disabledpeoples participation and demonstrate an understanding of local issuesaffecting disabled people.Supporting evidenceCriteria2) Demonstrate a good understanding of the barriers faced by disabledpeople in obtaining and retaining main stream employment. With evidence ofhow you have supporting disabled people to overcome these barriers.Supporting evidenceCriteria3) The ability to work with a range of people, especially government officialsand voluntary sector organisations. In particular a proven track record ofinfluencing decisions and negotiating to deliver positive outcomesSupporting evidence 3
  4. 4. Criteria4) Demonstrate good interpersonal skills with a personal style that is incisiveand challenging, but not confrontational.Supporting evidenceCriteria5) Ability to develop project plans to deliver services to make a real differencein the community and to submit funding bids.Supporting evidence 4
  5. 5. Section 3: Additional InformationThis section is for you to note any additional information you want to includein support of your application.This can include details of your career history (if applicable) and otherrelevant experience, such as: employment, voluntary experience, involvementin the community, committee experience, or caring responsibilities. It shouldinclude any public appointments you have held. Alternatively, for thissection only, you may provide a CV (maximum 2 pages).1) Name and Address of Employer or OrganisationTitle / Positions HeldDetails (Including Nature of Work and Time Commitment)Dates From and To2) Name and Address of Employer or OrganisationTitle / Positions HeldDetails (Including Nature of Work and Time Commitment)Dates From and To 5
  6. 6. 3) Name and Address of Employer or OrganisationTitle / Positions HeldDetails (Including Nature of Work and Time Commitment)Dates From and To 6
  7. 7. Section 4: Register of Interest FormPlease submit a signed copy of the Register of Interest form which addressesthe issues of conflicts or improprieties, past or present that would impact onyour ability to carry out this role.Full Name:Position:Please register any links and relationships with organisations, individuals orbodies that may give rise to a potential conflict of interest.DirectorshipsPlease list all Directorships (held within the last two years), with a briefdescription of the company and any possible links to DWP or any otherGovernment Departments (directly or indirectly). Please include anypartnerships.1) CompanyPossible Links to DWPDate of AppointmentDate of Resignation2) CompanyPossible Links to DWPDate of AppointmentDate of Resignation 7
  8. 8. 3) CompanyPossible Links to DWPDate of AppointmentDate of ResignationOther Public Appointments1) RolePossible Links to DWPDate of AppointmentDate of Resignation2) RolePossible Links to DWPDate of AppointmentDate of Resignation3) RolePossible Links to DWPDate of AppointmentDate of Resignation 8
  9. 9. Close relations and friendsPlease list any possible conflicts of interests created by virtue of theemployment, directorships or significant shareholding of a close relation orfriend.1) NameCompanyPossible Links to DWPRelationship to Senior Manager2) NameCompanyPossible Links to DWPRelationship to Senior Manager3) NameCompanyPossible Links to DWPRelationship to Senior Manager 9
  10. 10. 4. Any other matterPlease list any other matter, which may give rise to a potential conflict ofinterest e.g. related consultancy contracts, external examinerships withacademic institutions, membership of committees/organising bodies withdecision making or purchasing powers, including Trusteeship of charitable orother bodies.1) NameCompanyPossible Links to DWPRelationship to Senior Manager2) NameCompanyPossible Links to DWPRelationship to Senior Manager3) NameCompanyPossible Links to DWPRelationship to Senior Manager 10
  11. 11. I certify that the information included within this register is, to the best of myknowledge and belief true and accurate and complete.Name:Signature:(If sent by email please state here.)Date:Please insert your full name in the box above to declare that the informationgiven in this Register of Interest form is complete and correct. 11
  12. 12. Section 5: RefereesPlease provide names and contact telephone numbers of two people, whomay be called to act as referees for you. They must have authoritative andpersonal knowledge of your recent achievements in a professional or publicservice capacity. References will be taken up after short listing and inadvance of the final interview. Please provide details of the most accessibleway to contact them.1) NameContact Details2) NameContact Details 12
  13. 13. Section 6: Personal ConsentPlease sign the following declaration:I declare that the information given in this application form is complete andcorrect. I have read the information pack and can confirm that I am eligible tobe considered for appointment to this body. I understand that if any of theinformation provided in this form is untrue I may be removed from office. Icertify that I will immediately inform the Department of any changes incircumstances that affect the answers I have given.I also confirm consent to share the information in this form with members ofthe panel, Ministers, those responsible for the recruitment process in DWP.This information will be handled in line with the Data Protection Act 1998 andwill be used solely for the purposes of assessing suitability for this role.Some of the information supplied will be placed in the public domain ifsuccessful.Name:Signature:(If sent by email please state here.)Date:Please insert your full name in the box above to acknowledge you have readand understood the declaration of personal consent. 13
  14. 14. Section 7: Political Activity QuestionAll applicants for a public appointment should complete the question below.This question is asked as it enables the monitoring of political activity ofcandidates for a public appointment in so far as it is already in the publicdomain. Neither activity nor affiliation is a criterion for appointment (exceptwhere statute dictates specific representation).If you are successful, the information provided will be published with theannouncement of your appointment.Please indicate which of the following activities you have undertaken duringthe past five years by ticking the appropriate box and by providing details ofyour involvement. Name the political party or body for which you have beenactive. If you have been or are an Independent or have sought or obtainedoffice as a representative of a particular interest group, you should state this.You should tick all relevant categories.Obtained office as a Local Councillor, District Councillor, MP, MEP, MLAetc.Acted as a political agentHeld Office such as Chair, Treasurer or Secretary of a local branchUndertaken any other political activity which you consider relevantMade a recordable donation to a political partyNone of the above activities 14
  15. 15. Name of Party for which activity undertaken:Details of involvement:Name:Signature:(If sent by email please state here.)Date:Note: This form is for monitoring purposes only and therefore will bedetached from your application and will not be seen by any selection panels.However, it is appreciated that such activities may have given you relevantskills, including experience gained from committee work, collective decisionmaking, resolving conflict and public speaking. If, therefore, you have hadsuch experience and you consider it relevant to your application for this post,you should include it separately in the main body of your application form.You should not, however, identify the relevant political party in the applicationform. 15
  16. 16. Section 8: Equal OpportunitiesAll Government Departments aim to provide fair and equal access to publicappointments. Questions on gender, ethnic origin, age and disability will helpthe Department to monitor the effectiveness of its strategy throughinformation from those applying for and obtaining appointments. This form willnot be seen by the selection panel. Your answers will be treated confidentiallyand will not affect your application in any way. Alternatively, the form can bereturned uncompleted if you do not wish to have these details recorded.Ethnic Origin InformationThese categories are not about nationality, place of birth or citizenship. Theyrelate to broad ethnic group categories as recommended by the EHRC.When you have read them all please tick the box that most accuratelydescribes you.Asian or Asian British:IndianPakistaniBangladeshiOtherBlack or Black British:CaribbeanAfricanOtherChinese or Other:ChineseOtherMixed:White and Black CaribbeanWhite and Black AfricanWhite and AsianOtherWhite:BritishIrishOther 16
  17. 17. Other Ethnic Origin (please describe)AgeAre you?16-2526-3536-4546-5556+Prefer not to sayGenderAre you?MaleFemalePrefer not to saySexual OrientationAre you?HeterosexualLesbian/GayBisexualAsexualPrefer not to say 17

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