Registration Form - Education

HQ Ref:
To ensure that your application proceeds smoothly, pre-appointment checks can
be put in place and to help avoid any delay, please:
a) complete all sections of this form in BLACK INK / TYPE and in CAPITALS if hand written
b) note that all sections must be completed by the Applicant

1. Personal Details
Title: Mr.

Date of Birth: 01/07/1975

Surname: HABOOL AL-SHAMERY

Forename(s): MAITHAM

HQ Number (Internal Use Only)

2. Disclosure
Boston Rose are required by CRB regulations to carry out an Enhanced Disclosure Certificate (CRB)
issued by the Criminal Records Bureau or Disclosure Scotland.
Please select one of the following options
a) I have submitted a copy of my CRB to Boston Rose which is no more than 12
months old whilst my new CRB is being processed. I enclose my completed CRB
Application Form.
b) I do not hold a current CRB, so have enclosed a completed CRB Application Form
and I have supplied the necessary original ID documentation to you with the
application
(Please ensure you complete section 3 of the registration form if you tick this
option)

YES

Please confirm:

NO

YES

Legislation provides that the applicant should pay for the CRB check. No mark up is charged by
Boston Rose.
I enclose a cheque made payable to Boston Rose for 46.00 for the CRB fee

I consent to Boston Rose passing a CRB relating to me onto interested third parties
(such as a College)
*We will not be able to process your CRB until we have received a cheque for the sum above. Prompt payment
will avoid any delays of your start date or cancellation of your appointment.*

DNS Ev1 : Boston Rose 2009

Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963

Company Number 5015384

3. Rehabilitation of Offenders Act 1974 (Exceptions) (Amendments) Order 1986 (SI

1986/1249) (ROA)
Please circle as appropriate

Yes / No

Have you been convicted of a criminal offence?

Yes / No

Do you have knowledge of any pending prosecutions in respect of alleged

criminal offences (excluding road traffic offences not involving injury to a third party) or
a sentence of imprisonment?

Please provide details below if you have answered yes to either of the above:Date

Offence

Sentence

Assignments may mean you are involved in teaching or training students under the age of 18, or
students with learning difficulties or disabilities. Your registration with Boston Rose and your assignment
is therefore classed as exempt from the provisions of the ROA. You may be required to apply for an
Enhanced Disclosure police check through the Criminal Records Bureau (an executive agency of the
Home Office) or if in Scotland, the Scottish Criminal Records Bureau. Consequently you are NOT entitled
to withhold information about convictions, which for other purposes are spent under ROA. All
information provided by you in the section below will be checked with the relevant authorities.

DNS Ev1 : Boston Rose 2009

Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963

Company Number 5015384

4. Referees
Please nominate two referees, one of whom must be your latest employer. If you have been working
through an agency please provide the contact details for your line manager at your place of work and
not details of the agency.
Boston Rose will take up both references, so if you have any concerns or timing issues relating to us
contacting your referees please indicate so and provide details here:

Current / Most Recent Employer

Previous Employer

/ No
Contact before position accepted: Yes

Name:

Name: Dr David Richardson

Company :

Company :

Position Held:

Faculty of Engineering Design and Mathematics

University of the West of England

Position Held: Senior Lecturer

Address:

Address:

Postcode:

Faculty of Engineering Design and Mathematics

University of the West of England
Frenchay
Bristol

Postcode: BS16 1QY

Tel No:

Tel No: 0117 328 2223

Fax No:

Fax No:

E-mail address:

E-mail address: David4.Richardson@uwe.ac.uk

Relationship to Applicant:

Relationship to Applicant:
Programme Manager

Education Referee
Please complete this section if you have worked in the Education sector previously but they are not your
latest employer or previous employer:
Company:
Contact Name:
Contact Position:
Contact Tel:
Contact E-mail:

DNS Ev1 : Boston Rose 2009

Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963

Company Number 5015384

5. Qualifications
Please
1. List all education, professional & trade qualifications that you have been awarded or are
currently studying for
2. Supply Original Certificates for all qualifications stated
3. Use the Continuation Sheet (in the Appendix (Section 5)) as necessary
SCHOOL QUALIFICATIONS
Do you hold a level 2 (GCSE, GCE, CSE Grade 1, Key Skills or equivalent) qualification in:
English? Yes [] No [ ]
Mathematics? Yes [] No [ ]

QUALIFICATIONS SCHOOL, FURTHER AND HIGHER EDUCATION, TEACHING

From

To

Institution

FT/PT

Qualification

PROFESSIONAL or TRADE MEMBERSHIP

Are you registered with the IFL (Institute for Learning)
or GTC (General Teaching Council)?

IFL
Yes [ ] No [ ]
Membership Number:

Please tick as appropriate

GTC
Yes [ ] No [ ]
Membership Number:

Main teaching subject taught (if applicable):

DNS Ev1 : Boston Rose 2009

Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963

Company Number 5015384

Grade/Class

6. Health
Anyone appointed to a post involving regular contact with children or young people must be medically
fit (Education (Health Standards) (England) Regulations 2003). Please provide any information about
your past and present health that may affect your ability to undertake tasks while working on an
assignment, including:

any reasonable adjustments that could be made to help you carry out your role
whether you consider yourself disabled
receipt of any incapacity benefits
health conditions affecting your ability to work
medication or conditions that may impair your safety
any health problems that may be of concern when working with children (e.g. mental or
psychological illness, infections or diseases)
any absences from work for health reasons during the last 12 months.
All information supplied will be kept strictly confidential

Health Information

7. Data Protection
Boston Rose complies with the Data Protection Act 1998 and is registered for the processing of
information. Boston Rose may also be able to provide you work and opportunities through group
companies. Please only put an X in the brackets if you do not wish your details to be made available to
other group companies [ ]

8. Equal Opportunities
Boston Rose strives to work within legislative requirements as well as promoting best practice. If you
wish to assist us with Equal Opportunities Monitoring please complete the Form in Appendix 1 which
will be detached from this Application Form and held by HR

DNS Ev1 : Boston Rose 2009

Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963

Company Number 5015384

9. Declaration
Information you provide in and together with this Application Form will be checked. It is also your
responsibility to inform us of any significant changes to your circumstances. If Boston Rose reasonably
believes that you have withheld relevant details or provided misleading or false information on or with
this Application Form then your assignment may be terminated without payment on immediate notice,
you may be removed from our Database, future references could be affected, Boston Rose may choose
not to introduce you to other assignments and may take any further action it deems appropriate.
Declaration: I declare that all the answers I have given and the information I have provided are
accurate, complete and true to the best of my knowledge and belief, and that Boston Rose may
disclose parts of this application and any accompanying documents with prospective and actual
employers if requested.
Applicant Name (print):_______________________
Signature:__________________________________
Date: _____________________________________
For Boston Rose use only
Reviewed:
Date:
Suitability: Fit/Unfit to work

DNS Ev1 : Boston Rose 2009

Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963

Company Number 5015384

Appendix 1) Equal Opportunities Monitoring Form

Boston Rose is committed to equal opportunities. In order to monitor the effectiveness of our Equal Opportunities
Policy, we request that all Applicants complete the section below. This section will be separated from the
Application Form on receipt and kept securely. It will not be passed on to the end client.
Surname
Gender

Forename
Female

Male

Age

Ethnic Origin
Asian/Asian British
Bangladeshi
Indian
Pakistani
Any Other

White and Asian

White and Black African
Any Other

Black/Black British

White

African
Caribbean
Any Other
Other not listed

British
Irish
Any Other

If you have a disability falling within the terms of the Disability Discrimination Act, for which the end client may
need to make a reasonable adjustment, please provide information below

I give consent to Boston Rose recording and processing information about me in the above categories in order to
monitor the effectiveness of their Equal Opportunities Policy. My consent is conditional upon Boston Rose
complying with the obligations and duties under the Data Protection Act 1998

Signature

DNS Ev1 : Boston Rose 2009

Date

Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963

Company Number 5015384

Appendix 2) Continuation Sheet

QUALIFICATIONS SCHOOL, FURTHER AND HIGHER EDUCATION, TEACHING
From

To

Institution

FT/PT

Qualification

Any other expansion required (please label clearly)

DNS Ev1 : Boston Rose 2009

Temp Desk Contact: Tel 0203 006 5832 Fax 0203 060 3963

Company Number 5015384

Grade/Class