1.

2.

13.

Details of the bedroom(s) available for hosting student(s) - please tick all that apply:

14.

Details of the property: Please indicate whether or not the property has the following:

15.

16.

18.

Has any full-time resident in the household ever:

This position is exempt from the Rehabilitation of Offenders Act 1974 and therefore all convictions, cautions, written warnings, bind overs, including those regarded as ‘spent’ must be declared. If you have answered ‘YES’ to any of the questions above, please supply further details along with the relevant dates on a separate form marked Private and Confidential for the attention of the Director of Guardianship Services.

Section 70a of the Children Act 1989 states that a person who gives information which he/she knows to be false/misleading or makes a statement in this notice will be guilty of an offence and liable on summary conviction to a fine.

Please note: having a criminal record nay not necessarily stop you from working with our company; this will depend upon the nature of the offence.

First Person

Second Person

Please provide details of the names of two character referees one of whom should be a professional person and must have known you for at least two years:

Reference One

Reference Two