Application Form

Skills for Care

Peripatetic Assessor Network

Last Name First Name

Job Title

1
Contact Address

Postcode

Telephone number Fax number

E-Mail Address
Mobile number

Qualifications:

Brief description of job and role (please attach your CV and copies of your
assessor certificates – we will not send these to any other person but
training providers may request copies direct from you at a later date):

Have you had any experience of assessing candidates since qualifying and if
so how many candidates?

Which NVQ are you Please tick the relevant NVQ and state level:
occupationall
Care RMA
y competent
to assess? Early Years Mgt
Admin

2
How many hours per month would you like to be considered for?

Are you able to work flexibly / out of office hours? If yes give details….

Which sub-region of London would you prefer to be considered for and

why? ( N West / N Central / N East / S East / S West Note – N Central is Islington
, Camden, Haringey, Enfield, Barnet ) ) Please state boroughs if appropriate or
indicate ALL Boroughs

Please give 2 references.

If possible one of these references should be the contact details for an
Internal verifier if you know one. If you do not know one please give two other
references.

Reference 1: Reference 2:

In order to ensure that only candidates who are registered with the network are
working with the training providers, we require two passports size picture per
candidate. This will be sent to training providers along with each candidates
CV.

I agree / do not agree (*) to my photo being kept on records and sent to
potential employers as and when necessary.

(*) delete as appropriate

I understand that acceptance onto the peripatetic assessor network is in

no way a guarantee of work, nor does it form a contract with Skills for
Care.

Applicant

Date

Name Signed

3
 Monitoring information

In order to ensure that our training is available to all members of the community,
please help us by filling in this short questionnaire. Thanks you for your cooperation.

Please tick the appropriate box

Gender
 Male  Female
Age
 Under 20 years  20 – 24 years  25 - 34 years  35 - 44 years
 Over 44 years

Disability How would you describe yourself?

Sensory
 No Disability  Dyslexia  Impairment  Mobility Difficulties
 Unseen Disability  Multiple Disability  Disability Not Listed Above

Ethnic Monitoring Which of the following best describe your ethnic origin?
Asian

 Bangladeshi  Chinese  Indian  Pakistani

 Other ____________
Black
Other
 Caribbean  Somali  Other African  ___________
Mixed
White & Black White & Black Other
 White & Asian  African  Caribbean  ___________
White

 English  Irish  Scottish  Welsh

 Other ____________
Return this 3 page form to :
Lynn James, Operations Director, Quay Assessment Training Ltd
43a Sidcup Hill , Sidcup, Kent, DA14 6HJ
Tel 020 302 4821
Please mark IN CONFIDENCE