Disabled People’s User-Led Organisations (DPULOs) play a significant role in promoting the role and value of disabled people in their local community. The Strengthening DPULOs Programme was launched in July 2011 to provide a range of practical and financial support to DPULOs to support them to be strong and sustainable. I am recruiting additional Ambassadors to further extend the Strengthening DPULOs Programme. For further information, please visit: http://odi.dwp.gov.uk/odi-projects/user-led-organisations/ambassadors-application.php

1. Application Form
Ambassador to Office for Disability Issues promoting the role
and value of disabled people in the local community based in
NW England, Scotland and Wales
This application form is separated into 8 sections (17 pages, including this
cover page). Please read each page carefully and ensure every question is
completed.
If you are handwriting your application form, please make sure your writing is
legible. Please use black ink as this photocopies best.
We are keen to make reasonable adjustments for applicants. If you would like
to use another format for your application, please contact us.
Applications should be sent to: Audrey Daft, Ground Floor, Caxton House,
Tothill Street, London SW1H 9NA. This can either be by e-mail or by post.
Emailed applications should be sent to: Audrey.daft@DWP.GSI.GOV.UK
The closing date for applications is 8th June 2012 at 10am.
Late applications will not be considered.
There will not be a guaranteed interview for disabled people who do not meet
the minimum criteria. As we are expecting a lot of interest in these posts we
expect the calibre of applications to be very high.
Can you tell me where you heard about this role?
Disability Now Y/N
Guardian/Times Newspaper Y/N
On the Office for Disability Issues Website Y/N
Twitter/Facebook Y/N
Other (please give details)
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2. Section 1: Personal Details
Role Reference Number:
Title (Mr/Mrs/Miss/Ms/Other (please specify):
Name:
Home Address:
Home Telephone:
Mobile Telephone:
E-mail address:
Please add any other contact details (if applicable) and state your preferred
means of contact e.g. telephone, email etc:
Please list any dates when you will be unavailable between Monday 2nd July
and Monday 9th July 2012.
I have read the definition of a disabled person in the Candidate Information
pack and consider that I am a disabled person for the purpose of this
application.
Please indicate as appropriate:
Yes
No
There will not be a guaranteed interview for disabled people who do not meet
the minimum criteria. As we are expecting a lot of interest in these posts we
expect the calibre of applications to be very high.
2

3. Section 2: Knowledge and Experience
Please respond to each of the criteria numbered 1-8 below. Please provide
examples of your knowledge and experience and the outcomes you have
achieved to demonstrate your suitability. Please limit your examples for each
criterion to 400 words. The boxes will expand as you type.
If you are writing your application form, you may continue on additional
sheets if required.
Criteria
1) Experience of working within local communities to increase disabled
peoples participation and demonstrate an understanding of local issues
affecting disabled people.
Supporting evidence
Criteria
2) Demonstrate a good understanding of the barriers faced by disabled
people in obtaining and retaining main stream employment. With evidence of
how you have supporting disabled people to overcome these barriers.
Supporting evidence
Criteria
3) The ability to work with a range of people, especially government officials
and voluntary sector organisations. In particular a proven track record of
influencing decisions and negotiating to deliver positive outcomes
Supporting evidence
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4. Criteria
4) Demonstrate good interpersonal skills with a personal style that is incisive
and challenging, but not confrontational.
Supporting evidence
Criteria
5) Ability to develop project plans to deliver services to make a real difference
in the community and to submit funding bids.
Supporting evidence
4

5. Section 3: Additional Information
This section is for you to note any additional information you want to include
in support of your application.
This can include details of your career history (if applicable) and other
relevant experience, such as: employment, voluntary experience, involvement
in the community, committee experience, or caring responsibilities. It should
include any public appointments you have held. Alternatively, for this
section only, you may provide a CV (maximum 2 pages).
1) Name and Address of Employer or Organisation
Title / Positions Held
Details (Including Nature of Work and Time Commitment)
Dates From and To
2) Name and Address of Employer or Organisation
Title / Positions Held
Details (Including Nature of Work and Time Commitment)
Dates From and To
5

6. 3) Name and Address of Employer or Organisation
Title / Positions Held
Details (Including Nature of Work and Time Commitment)
Dates From and To
6

7. Section 4: Register of Interest Form
Please submit a signed copy of the Register of Interest form which addresses
the issues of conflicts or improprieties, past or present that would impact on
your ability to carry out this role.
Full Name:
Position:
Please register any links and relationships with organisations, individuals or
bodies that may give rise to a potential conflict of interest.
Directorships
Please list all Directorships (held within the last two years), with a brief
description of the company and any possible links to DWP or any other
Government Departments (directly or indirectly). Please include any
partnerships.
1) Company
Possible Links to DWP
Date of Appointment
Date of Resignation
2) Company
Possible Links to DWP
Date of Appointment
Date of Resignation
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8. 3) Company
Possible Links to DWP
Date of Appointment
Date of Resignation
Other Public Appointments
1) Role
Possible Links to DWP
Date of Appointment
Date of Resignation
2) Role
Possible Links to DWP
Date of Appointment
Date of Resignation
3) Role
Possible Links to DWP
Date of Appointment
Date of Resignation
8

9. Close relations and friends
Please list any possible conflicts of interests created by virtue of the
employment, directorships or significant shareholding of a close relation or
friend.
1) Name
Company
Possible Links to DWP
Relationship to Senior Manager
2) Name
Company
Possible Links to DWP
Relationship to Senior Manager
3) Name
Company
Possible Links to DWP
Relationship to Senior Manager
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10. 4. Any other matter
Please list any other matter, which may give rise to a potential conflict of
interest e.g. related consultancy contracts, external examinerships with
academic institutions, membership of committees/organising bodies with
decision making or purchasing powers, including Trusteeship of charitable or
other bodies.
1) Name
Company
Possible Links to DWP
Relationship to Senior Manager
2) Name
Company
Possible Links to DWP
Relationship to Senior Manager
3) Name
Company
Possible Links to DWP
Relationship to Senior Manager
10

11. I certify that the information included within this register is, to the best of my
knowledge and belief true and accurate and complete.
Name:
Signature:
(If sent by email please state here.)
Date:
Please insert your full name in the box above to declare that the information
given in this Register of Interest form is complete and correct.
11

12. Section 5: Referees
Please provide names and contact telephone numbers of two people, who
may be called to act as referees for you. They must have authoritative and
personal knowledge of your recent achievements in a professional or public
service capacity. References will be taken up after short listing and in
advance of the final interview. Please provide details of the most accessible
way to contact them.
1) Name
Contact Details
2) Name
Contact Details
12

13. Section 6: Personal Consent
Please sign the following declaration:
I declare that the information given in this application form is complete and
correct. I have read the information pack and can confirm that I am eligible to
be considered for appointment to this body. I understand that if any of the
information provided in this form is untrue I may be removed from office. I
certify that I will immediately inform the Department of any changes in
circumstances that affect the answers I have given.
I also confirm consent to share the information in this form with members of
the panel, Ministers, those responsible for the recruitment process in DWP.
This information will be handled in line with the Data Protection Act 1998 and
will be used solely for the purposes of assessing suitability for this role.
Some of the information supplied will be placed in the public domain if
successful.
Name:
Signature:
(If sent by email please state here.)
Date:
Please insert your full name in the box above to acknowledge you have read
and understood the declaration of personal consent.
13

14. Section 7: Political Activity Question
All applicants for a public appointment should complete the question below.
This question is asked as it enables the monitoring of political activity of
candidates for a public appointment in so far as it is already in the public
domain. Neither activity nor affiliation is a criterion for appointment (except
where statute dictates specific representation).
If you are successful, the information provided will be published with the
announcement of your appointment.
Please indicate which of the following activities you have undertaken during
the past five years by ticking the appropriate box and by providing details of
your involvement. Name the political party or body for which you have been
active. If you have been or are an Independent or have sought or obtained
office as a representative of a particular interest group, you should state this.
You should tick all relevant categories.
Obtained office as a Local Councillor, District Councillor, MP, MEP, MLA
etc.
Acted as a political agent
Held Office such as Chair, Treasurer or Secretary of a local branch
Undertaken any other political activity which you consider relevant
Made a recordable donation to a political party
None of the above activities
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15. Name of Party for which activity undertaken:
Details of involvement:
Name:
Signature:
(If sent by email please state here.)
Date:
Note: This form is for monitoring purposes only and therefore will be
detached from your application and will not be seen by any selection panels.
However, it is appreciated that such activities may have given you relevant
skills, including experience gained from committee work, collective decision
making, resolving conflict and public speaking. If, therefore, you have had
such experience and you consider it relevant to your application for this post,
you should include it separately in the main body of your application form.
You should not, however, identify the relevant political party in the application
form.
15

16. Section 8: Equal Opportunities
All Government Departments aim to provide fair and equal access to public
appointments. Questions on gender, ethnic origin, age and disability will help
the Department to monitor the effectiveness of its strategy through
information from those applying for and obtaining appointments. This form will
not be seen by the selection panel. Your answers will be treated confidentially
and will not affect your application in any way. Alternatively, the form can be
returned uncompleted if you do not wish to have these details recorded.
Ethnic Origin Information
These categories are not about nationality, place of birth or citizenship. They
relate to broad ethnic group categories as recommended by the EHRC.
When you have read them all please tick the box that most accurately
describes you.
Asian or Asian British:
Indian
Pakistani
Bangladeshi
Other
Black or Black British:
Caribbean
African
Other
Chinese or Other:
Chinese
Other
Mixed:
White and Black Caribbean
White and Black African
White and Asian
Other
White:
British
Irish
Other
16

17. Other Ethnic Origin (please describe)
Age
Are you?
16-25
26-35
36-45
46-55
56+
Prefer not to say
Gender
Are you?
Male
Female
Prefer not to say
Sexual Orientation
Are you?
Heterosexual
Lesbian/Gay
Bisexual
Asexual
Prefer not to say
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