PQASSO FOR WALES MENTOR PROGRAMME – APPLICATION FORM THIS

PQASSO for Wales mentor programme – application form

This application form is for individuals wishing to train to become licensed PQASSO mentors for NCVO, as part of the PQASSO for Wales project.

Please ensure that you have read the PQASSO mentor programme guidelines before completing this form.

PLEASE REMEMBER TO SUBMIT YOUR CURRENT CV WITH YOUR COMPLETED APPLICATION FORM

Section 1: personal information

Name
Job title
Employing organisation (if applicable)
Organisation’s address
Postcode
Work telephone number
Work email address
I am currently employed in	Third sector	Public sector	Private sector	Self-employed
Personal telephone number (this will only be used as an additional contact number if we need to contact you urgently)
Are you a Welsh speaker	Yes		No

My work is covered by my own/my employer’s professional indemnity insurance cover

Yes No

Declaration - to be completed by the employing organisation (where applicable). This should be signed by the Chair, Chief Executive or a member of the senior management team.

“I confirm that I support this application and will release the applicant, if successfully recruited as a PQASSO mentor, to attend the four-day mentor training course and to fulfil the role and responsibilities of a PQASSO mentor set out under point 6 of the guidelines to this application form”

Name
Job title
Telephone number
Signature
Date

Declaration - to be completed by applicant

“I confirm that I have read and understood the application guidelines. I declare that all the information contained within this application form is, to the best of my knowledge, true”

Name

Signature

Date

Section 2: training course dates

Please indicate which course you wish to attend. Successful applicants must attend all four days of the training course and pass the assessment to become a licensed PQASSO mentor. Failure to attend all four days of the training course will mean that your organisation/your employing organisation will not receive any payments and you will not be able to become a licensed PQASSO mentor.

Please indicate which is your first choice and second choice course to attend.

Course 1 – South Wales	Course 2 – North Wales	Course 3 – West Wales	Course 4 – Mid Wales
1^st choice	1^st choice	1^st choice	1^st choice
2^nd choice	2^nd choice	2^nd choice	2^nd choice
Location	Location	Location	Location
Cardiff Bay	Llanrwst	Carmarthen	Llandrindod Wells
Dates	Dates	Dates	Dates
2^nd-4^th June 2015 (training)	16^th-18^th June 2015 (training)	15^th – 17^th September 2015 (training)	13^th – 15^th October 2015 (training)
9^th June 2015 (assessment)	23^rd June 2015 (assessment)	22^nd September 2015 (assessment)	20^thOctober 2015 (assessment)

Section 3: your work as a mentor

Please indicate in which geographical area/s you intend to work as a mentor, if successful (these are based on current Local Authority boundary areas for ease of identification)

North Wales	Mid and South West Wales	Central South
Anglesey	Carmarthenshire	Bridgend
Conwy	Ceredigion	Caerphilly
Denbighshire	Pembrokeshire	Merthyr Tydfil
Gwynedd	Powys	Rhondda Cynon Taff
Flintshire	Swansea	Vale of Glamorgan
Wrexham	Neath Port Talbot
South East
Blaenau Gwent
Cardiff
Monmouthshire
Newport
Torfaen

Please add any explanatory comments if needed:

Section 4: your knowledge, skills and experience

PLEASE SUBMIT YOUR CURRENT CV WITH YOUR COMPLETED APPLICATION FORM

Personal statement: please outline your reasons for applying to become a PQASSO mentor and your suitability for the role. Please ensure that you address each point in the person specification in turn, include clear examples, and use each point as a heading (see point 10 in the guidelines to this application form).

We also need to recruit mentors who can provide training and support to organisations in Welsh, where needed. If you are a Welsh speaker, please indicate, when addressing the person specification, whether you are happy to deliver training and support in Welsh; this will include preparing presentations and other materials. Also, please include examples of when you have provided training and support to organisations in Welsh.

Section 5: checklist (please tick)

All parts of the application form have been fully completed
You have signed the declaration
Where applicable, the Chair, Chief Executive or a member of the senior management team has signed the employing organisation’s declaration
You have attached your CV
You have completed and attached the Equal Opportunities form
You have checked that, if you are successful, you will be able to attend all four days of your chosen training course

Please return your completed application form and your current CV to [email protected]

Tags: application form, completed application, programme, pqasso, mentor, application, wales