Isle of Wight Council

	NOMINATION FORM FOR ISLE OF WIGHT COUNCIL APPOINTED GOVERNORS
	This form should be completed by any person interested in applying to become a governor.
	Your Details

	Title
*	Forename
	Middlename/Initials
*	Surname

*	Building/house name/number
*	Street address
*	Town Name
	County
*	Postcode
	Tel Number (include area code)
	Email address

Date of Birth

Please note your Date of Birth is only required for the List 99 check. List 99 is the list of teachers or workers prohibited or restricted from working with children or young people. You will not be allowed to be a governer if you are on this list.

Further Details required

	Your Occupation
	Previous Service and Current Appointments: Please list any previous experience as Governor or specify any other Governorships currently held, and when the terms of office will end.
	Sector Preferred	Primary Middle High Special

	Area Preferred
	Any other relevant information:

Notes

PERSONS DISQUALIFIED FROM BECOMING A GOVERNOR Persons cannot be a governor if they: 1. have been convicted of certain criminal offences 2. are an undischarged bankrupt 3. are disqualified from being a company director 4. are disqualified from being a charity trustee 5. disqualified from being a proprietor of an independent school 6. are detained under the Mental Health Act 1983 7. are under the age of 18 8. are included in the list teachers or workers prohibited or restricted from working with children or young people (known as List 99) Other disqualifications: 1. you can be disqualified from being a governor is you refuse to an application being made to the Criminal Records Bureau for a criminal records certificate. 2. you can be disqualified from being a governor if you do not attend your governing body meetings for six months.

Declaration

I certify that the above information is correct and I am willing to accept the appointment if offered.

Signed ......................................................................................... Name........................................................................................... Date.............................................................................................

Please complete this form and return it to: KIRSTIE RANN, Governors' Support Service Officer, Directorate of Children's Services, County Hall, Newport, IW Tel: (01983) 823458 Fax: (01983) 823463

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 07/03/2013