! Trustee application form ! CLOSING DATE FOR APPLICATIONS: 7 ! Application number th April 2015 Please submit a short curriculum vitae (2 page max) together with this application form. Please note that this is in addition to the information given on the application form, not in substitution for it. The Equal Opportunities Monitoring Information should be completed and submitted separately to [email protected] or HR Service Centre, Alzheimer’s Society, Devon House, 58 St Katharine’s Way, London, E1W 1LB. This form should be completed in black ink or black type. Personal details ! Surname ! Other names ! Address ! ! ! ! ! Telephone/textphone/fax/mobile (Please indicate which) Other ! ! Email ! Home ! Do you have any previous Volunteer/Trustee experience? ! Yes No (please check appropriate box) ! If yes, please give details ! Please return the completed form to [email protected] and put TU4451 in the subject line of your email or mark in letter header if sending by post to: Alex Morley, Alzheimer’s Society, Devon House, 58 St Katharine’s Way, London E1W 1LB T: 020 7423 3506 F: 020 7423 3501 W: www.alzheimers.org.uk Registered charity no 296645. A company limited by guarantee and registered in England no 2115499. APPLICATION FORM PAGE 1 ! OF 6 ! ! ! ! ! ! ! ! ! ! I understand and am able and willing to commit necessary time, preparation and effort to the proper discharge of the responsibilities of a trustee. ! ! ! ! Please tell us how you fulfill the criteria In each section below, please give a brief outline of how your skills, knowledge and experience fit the criteria. Please give demonstrable examples wherever possible to support your application. ! Summarise why you want to be a trustee and how you feel you could contribute to the trustees’ work for the Society? Please limit your response to 300 words. !! !! !! !! !! !! !! !! !! !! Knowledge and Experience (Essential) o A clear understanding of the role of a trustee and the willingness and the commitment to devote the necessary time, preparation and effort to the proper discharge of the responsibilities of a trustee o Experience of operating in a senior role o Brings a broad knowledge of social, charitable, management and governance issues Please limit your response to 250 words. APPLICATION FORM PAGE 2 ! OF 6 ! !! !! !! !! !! !! ! ! !! !! !! !! !! !! Abilities and skills (Essential) o o o o o o A strategic thinker A sharp mind and good judgment Effective communicator: clear, concise and able to adapt to the needs of the audience Proactive, willing to offer constructive challenge and support judgments A team player, respecting different views and able to work with Board colleagues and the executive Able to build strong relationships and champion the Society. Please limit your response to 300 words. ! ! !! !! !! !! !! !! !! ! ! APPLICATION FORM PAGE 3 ! OF 6 ! Personal Qualities (Essential) o An empathy with and/or support for the aims and values of Alzheimer's Society and a willingness to spend time with people affected by dementia and bring that experience back to the Board. o A commitment to inclusion and diversity o Good listener, open to others’ views and welcomes feedback on own contribution. Please limit your response to 250 words. !! !! !! !! !! !! !! !! !! !! ! Suitability Are there any other facts, activities or connections which you feel might be raised in future about your suitability to hold the position of trustee and director at Alzheimer's Society, for example because they present or may present a conflict of interest? These may include issues such as personal relationships or membership of organisations or other circumstances, or because you may be disqualified by virtue of circumstances listed in Article 49 of the Society's Articles of Association. APPLICATION FORM PAGE 4 ! OF 6 ! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! !! APPLICATION FORM PAGE 5 ! OF 6 ! References ! Please give the name and address of two referees who can comment on your suitability for this role. Please note references from relatives are not acceptable. ! !Name !Position !Organisation Name Position Organisation Address Address ! Telephone !Telephone Email Email !Interviews will be held at our Devon House offices on 14 (pm) and 15 th th May 2015. Please let us know if you would NOT be able to attend an interview on this date: Please note that we will be unable to tell you whether you are being called for interview before the week beginning 23 April 2015. ! Declaration I confirm that the details given in this form are correct and understand that any false declaration may result in my removal from the board of trustees as outlined in the Society's Articles of Association. • • • • • • • • • • • I am aged 18 years or over at the date of this election or appointment I do not have an unspent conviction relating to any offence involving deception or dishonesty I am not an undischarged bankrupt nor have I made a composition or arrangement with, or granted a trust deed for, my creditors (ignore if discharged from such an arrangement) I am not subject to a disqualification order under the Company Directors Disqualification Act 1988 or to an Order made under section 429(b) of the Insolvency Act 1986 I have not been removed from the office of charity trustee or trustee for a charity by an Order made by the Charity Commissions or the High Court on the grounds of any misconduct or mismanagement (or equivalent in other jurisdictions) I am not disqualified under the Protection of Vulnerable Adults List I will, if elected, undertake a Disclosure and Barring Service check I have read the Charity Commission booklet CC3: The Essential Trustee I hereby explicitly consent to the Alzheimer’s Society holding my personal details within a manual or electronic filing system in relation to the Data Protection Act 1998 Appointment is dependent on becoming a member of the Society, if not one already I understand that if my application is progressed and / or if I am successful that appropriate DBS, credit, director checks will be undertaken. Signature ! APPLICATION FORM Date PAGE 6 ! OF 6 !
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