Access NI PO Box 1085 Belfast BT5 9BD

QUICK GUIDE FOR COMPLETING: ENHANCED DISCLOSURE APPLICATION FORM

Please complete this Application Form in CAPITAL LETTERS, using black ink. Applicants must complete Parts B, D, E, F and G and return the Form to the Registered Body for completion of Part A, H, I and J. Text in RED indicates fields that are mandatory on the Form - failure to complete the relevant information will result in the Form being returned unprocessed. PART A TYPE OF APPLICATION Indicate the type of Disclosure being requested by marking X in the appropriate box If you are unsure speak to your Registered Body who will advise you. A1 Please indicate which disclosure you are requesting, X one box only. A2 Enter Registered Body Name. A3 Enter 10 digit Registered Body Number. A4 Enter 10 digit Countersignatory Number (this should not be completed until after the Applicant has completed their details onto the Form). PART B PERSONAL DETAILS B1 Title - Mark X clearly in the appropriate box. Examples of other may be Reverend, Sister etc. B2 Surname - Enter your current Surname or last name. This will be the name that appears on your Disclosure Certificate. B3 Forename(s) - Please write your full first name not just initials. Include all your forenames if you have more than one. B4 Name usually known by - Use this section to include abbreviations, nicknames, etc by which you are more commonly known. B5 Surname at birth (if different) - If your surname at birth was different from your current surname please provide details and the date during which the names were used. This would only be applicable where your surname is different from your current surname i.e. changed by marriage, deed poll, etc. B6 Any other surname(s) used? - One of the boxes must be completed. This applies to all other previously used surnames you have used during your lifetime e.g. previous marriages, previous deed poll changes. Please also supply dates of changes. If Yes, complete F1- F4, if No go to B7. B7 Any other forename(s) used? - One of the boxes must be completed. This applies to all previous forenames you have used during your lifetime and the dates when these names were used. If Yes, complete F5 F8. B8 Gender - Mark on the appropriate box. If you are transgender and do not wish your employer to know of your previous gender, please contact AccessNI for advice.

B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21

Date of Birth - Enter the day, month and year you were born in the format DD/MM/YYYY - e.g. 04/03/1960. Place of Birth - Enter the name of the town and the country where you were born. National Insurance Number - Enter in spaces provided. This can normally be found on your payslip or any personalised Customs and Revenue Documents. Driving Licence Number - Enter the full Driving Licence number as found on your UK driving licence (point 5 on your driving licence refers). Do you hold a valid passport? - If No, go to B17, if Yes, you must complete B14, B15 and B16. Passport number - Enter Passport number. The passport should be valid. Nationality - Enter your nationality as indicated on your passport. Country of issue - Enter the Country your passport was issued in. Do you have an ISA registration number - If Yes, you must complete B18. ISA Registration number. Do you have a Scottish Vetting & Barring number - If Yes, you must complete B20. Scottish Vetting and Barring Number. Preferred contact number - Enter the number you would prefer AccessNI to contact you on if necessary.

PART C APPLICATION FOR REGISTRATION WITH ISA DO NOT COMPLETE FOR ENHANCED DISCLOSURE ONLY APPLICATIONS PART D APPLICANTS CURRENT AND DELIVERY ADDRESS D1-D6 Current Address - Please note that this will be the delivery address of the Disclosure Certificate. It should be your home address or, where this is not possible, Halls of Residence or temporary lodgings. Also include the date from which you have been a resident at this address. Each section must be completed. It is essential you supply a date at D6. If the date is within the last 5 years you must complete additional addresses to cover the full 5 years in Part E. Please give full address details, including postcode and dates of residence. If you do not provide a full 5 year address history your Form will be returned unprocessed. D7 D11 Delivery Address (if different) - This is the address to which you would prefer AccessNI to forward the Disclosure Certificate to. If it is the same as your current please leave blank. PART E ADDRESS HISTORY E1-E12 Previous Address(es) - If you have lived at your current address for less than 5 years you will need to provide your continuous address history for the last 5 years. You should include addresses outside the UK where appropriate. There must be no gaps in the dates provided; overlapping dates are acceptable. Please give full address details, including postcode. If your address history does not fit in the spaces provided you should use the approved Address Continuation Sheet which can be downloaded at http://www.dojni.gov.uk/index/accessni/application-forms/addresscontinuationsheet.pdf.

PART F - NAMES HISTORY Only applies if you have any previous surnames or forenames not recorded in Part B6 and B7. This should be completed if you have answered yes to B6 or B7. There must be no gaps in the dates; overlapping dates are acceptable. F1-F4 - Insert any additional surnames used, and dates. F5-F8 - Insert any additional forenames used, and dates. If necessary, please use an additional page, clearly writing your current name and date of birth at the top of the page. PART G DECLARATION BY APPLICANT Please read this section carefully as it is where you declare that all the information provided is correct and up to date. You must provide your signature and ensure that you print your full name and enter the date on this section of the Form. G1 Do you have any convictions - Have you ever been convicted in a court of law. Place a cross in the relevant box. G2 Signature of Applicant - Place your signature ensuring it stays within the box provided. G3 Date of Signature. G4 Insert your name in capitals. PART H REGISTERED BODY INFORMATION H1 Is the applicant applying for an AccessNI disclosure - Must be Yes. H2 Position applied for - Please ensure the position applied contains clear evidence for the request. It must be obvious the position qualifies for an enhanced disclosure. H3 Organisation name - the description you enter here will be recorded on the certificate H4 Will the work be carried out at the home of the applicant - if Yes, this will determine whether further checks on others in the household are required. One box must be X. H5 Is the disclosure required for the purpose of asking an exempted question? - Standard Disclosures can only be provided if the position applied for H2 is exempt from the provisions of set out in the Rehabilitation of Offenders (Northern Ireland) Order 1978 it is the responsibility of the Counter Signatory to ensure this is the case. If No is marked with X then the form will be returned unprocessed. H6 Is the disclosure required for a prescribed purpose - This must be X Yes. If you are unsure a list of prescribed purposes can be viewed on our website. H7 Are you entitled to know if the applicant is registered to work with children - Insert X in the appropriate box. One box must be X. H8 Are you entitled to know whether the applicant is registered to work with vulnerable adults. Insert an X in the appropriate box. One box must be X. H9 Have you established the true identity of the applicant by examining a range of documents as set out in AccessNI guidance, and verified the information provided in Parts B, C, D,E & F.. This box must be X Yes or the form will be returned. H10 Application Type - Please indicate if the post is for an New Post Holder, Existing Post Holder, Re Check of existing post holder. H11 Your reference number. If you require a number which you would like to appear on the certificate please enter it here i.e. an internal recruitment code. Do not use Countersignatory Number.

H7 & H8 ONE OR MORE BOX MUST BE YES. PART I PAYMENT I1 Please X the appropriate box. Account Invoices will issue at the beginning of each month and will include charges for Disclosure Certificates issued during the previous month. Acceptable payment methods can be found on page 1 of the invoice. No Payment (Volunteer) Access NI will provide free disclosure services to volunteers who meet the AccessNI definition. Further details can be found on http://www.dojni.gov.uk/index/accessni/who-usesani/volunteers.htm. PART J DECLARATION Please read the declaration and sign. This is the Registered Body statement that all documentation has been supplied and checked in accordance with AccessNI guidance. J1 Signature of Registered Person - This must be an original signature. J2 Date of signature - Must always be within 3 months from the date received by AccessNI. J3 Name in CAPITALS.