Application Form: Basic Disclosure

About this form

Please complete this application form in CAPITAL letters and use black ink. Failure to complete the
form correctly may result in a delay, or the form being returned unprocessed. Applicants should
complete Parts A, B, C, D and E. Subpostmaster should sign and date Part F.

Data Protection
Information on this form will be treated in confidence. Data supplied by you on this form will be
processed in accordance with the provisions of the Data Protection Act 1998.

PART A Applicant’s details

A1 Title Mr Mrs Miss Ms Other

If ‘Other’ please give details                                          

A2 Surname                                          

A3 Forename(s)                                          

A4 Surname at birth                                          
(if different)

Used until / /

A5 Any other surname(s) used? No If ‘No’, go to A6 Yes If ‘Yes’, complete D1.

A6 Any other forename(s) used? No If ‘No’, go to A7 Yes If ‘Yes’, complete D5.

A7 Gender Male Female

A8 Date of birth / /

A9 Place of birth Town                                          

Country                                          

A10 National Insurance Number

A11 Your Mother’s Surname/                                          

Maiden Name at her birth

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Retention period: Life of employment plus 7 years Owner: Recruitment Manager Version: 1 Last Reviewed: September 2012 Location: QMDL
 

PART B Applicant’s current and delivery address

B1 Current address                                          

                                           

 
B2 Town / City                                          

 
B3 Country                                          

 
B4 Postcode                

 
B5 Lived at this address since / /
 
 
 
PART C Address History

If you have lived at the address at B1-B5 for less than 5 years please provide details of all your
previous address(es) and dates of residence for the last 5 years. There must be no gaps in the dates;
overlapping dates are acceptable. Please start with the most recent address and work backwards.

Please use an additional page if necessary, clearly writing your current name at the top of the page.

C1 Address                                          

                                           

 
C2 Town / City                                          

 
C3 Country                                          

 
C4 Postcode                

C5 Lived at this address from / / to / /

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Retention period: Life of employment plus 7 years Owner: Recruitment Manager Version: 1 Last Reviewed: September 2012 Location: QMDL
 

PART C Address History Continued

C7 Address                                          

                                           

 
C8 Town / City                                          

 
C9 Country                                          

 
C10 Postcode                

C11 Lived at this address from / / to / /

PART D Names history

This section should only be completed if you have answered Yes to questions A5 or A6. You must
provide details of your previous name(s), along with dates these names were used. There must be no
gaps in the dates; overlapping dates are acceptable. Please use an additional page if necessary,
clearly writing your current name at the top of the page.

D1 Previous surname                                          

D2 date used from / / to / /

D3 Previous surname                                          

 
D4 date used from / / to / /
 
D5 Previous forename                                          

D6 date used from / / to / /

D7 Previous forename                                          

 
D8 date used from / / to / /

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Retention period: Life of employment plus 7 years Owner: Recruitment Manager Version: 1 Last Reviewed: September 2012 Location: QMDL
 
PART E Declaration by Applicant

Criminal Record Information – To be completed by the person to be security checked. Please note ALL sections are compulsory
A Criminal Conviction means any offence that you were found guilty of committing by Court or Court Martial including motoring offences
even if you did not attend. Answering ‘yes’ does not mean that Post Office Ltd cannot consider you for the role. Please note you should
declare any motoring offences which resulted in fines, points on your Driving Licence in the last 5 years or custodial sentences which
remain unspent in line with the Rehabilitation of Offenders Act 1974.
Please tick as applicable
Have you ever been convicted of any criminal offence which is currently unspent? Yes No

If you have ticked yes to the question relating to unspent criminal offence please provide details below, including:

The nature of the offence(s): _________________________________________________________________________

The date(s) of the offence(s): _________________________________________________________________________
The sentence(s) or court order(s): _________________________________________________________________________
Please tick as applicable
Do you have any Impending Prosecution(s)? Yes No

If you have ticked yes to the question relating to Impending Prosecution please provide details below, including:
The nature of the offence(s) you are being charged with: __________________________________________________________
Please tick as applicable
Have you ever received a Police Caution(s)? Yes No

If you have ticked yes to the question relating to Police Cautions please provide details below, including:
The nature of the Police Caution(s): _________________________________________________________________________
The date(s) of the Police Caution(s): _________________________________________________________________________
I understand that by giving my consent below, Post Office Ltd has permission to carry out security checks and for these to be audited by a
third party that is approved by Post Office Ltd. These security checks include a Criminal Record Check (Basic Disclosure Certificate) and
Recruitment Risk Register Check and may include Voters Roll and Financial Checks as deemed a requirement for the role.
I can confirm I am the person listed in this application. This consent lasts for a period of twelve months from the date of this application.
Post Office Ltd will use your personal data given during this application for the purpose of obtaining a Criminal Record Check (Basic
Disclosure Certificate) through Disclosure Scotland in accordance with the Data Protection Act 1998. This personal data will be exchanged
electronically between these aforementioned parties and the completed Criminal Record Check (Basic Disclosure Certificate) will be
returned to Post Office Ltd and opened by Post Office Ltd.
Further information on Basic Disclosures can be found at www.disclosurescotland.co.uk
I give consent for Post Office Ltd to carry out security checks using the data supplied during this application.
I give consent for Post Office Ltd to receive and open my Criminal Record Check (Basic Disclosure Certificate).
Signed: ___________________________________________________ Date: _______________________________________

PART F Declaration by authorised person

To be completed by the person authorised by Post Office Ltd who witnessed the completion of this form by the individual
I confirm that I have verified the identification and Right to Work of the above person and that the details given above exactly match the
details on the application submitted for working for Post Office Ltd, it’s subsidiaries (including Joint Venture Partners) or for one of its
Agents or Subcontractors, or the above person is an existing Post Office Ltd employee. I am aware that where the answer relating to
Impending Prosecutions is “yes” then the Security Vetting Checks cannot be run.

Signed: ____________________________________________ Date: ______________________________________________

Signatory Print Full Name: __________________________________ Telephone Number: ______________________________

Company: Name and Address ______________________________________________________________________________

(including postcode): _____________________________________________________________________________________

Post Office Ltd is registered in England and Wales. Registered No. 2154540. Registered Office 148 Old Street, London, EC1V 9HQ.
Post Office Ltd and the Post Office logo are registered trade marks of Post Office Ltd.
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Retention period: Life of employment plus 7 years Owner: Recruitment Manager Version: 1 Last Reviewed: September 2012 Location: QMDL