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The Highland Council

Convictions For Criminal Offences (Annex A)

Annex A

Post Title Applied for: Principal Teacher of History, Lochaber High School

Advert Ref No: MW/12/301/S

Surname: Roberts Title: Mr

Forename: Derrick Previous Surname/Maiden Name:

Place of Birth: BMH Munster (BFPO17) Date of Birth: 25/11/1975

Current Address: 9 Windsor Drive, Dartford Kent,DA13HW

Resident From: DD/MM/YYYY

Previous AddressesPlease list all addresses at which you have resided in the last 5 years.

Please continue on a separate sheet if necessary.

Address 1: 45 Eton Way, Dartford, Kent, DA1 5HL Resident From: DD/MM/YYYY 14/9/2010

Address 2: 15 Denver Road, Dartford, Kent, DA13LA Resident From: DD/MM/YYYY 01/02/2008

Address 3: 36 Harlington Road, Bexleyheath, Kent Resident From: DD/MM/YYYY 01/07/07

Address 4: Resident From: DD/MM/YYYY

Address 5: Resident From: DD/MM/YYYY

Address 6: Resident From: DD/MM/YYYY

Criminal Convictions

The nature of the duties of the post for which you have applied requires confirmation that you have had no convictionsfor offences which would reflect upon your suitability for appointment. With regard to positions defined under theProtection of Vulnerable Groups (Scotland) Act 2007 as regulated work, you are also required to confirm that youhave not been referred for inclusion onto a Disqualified from Working with Children List and/or Disqualified fromWorking with Protected Adult List. You should detail below any previous convictions for criminal offences. Subject tothe provisions of the Rehabilitation of Offenders Act, 1974 (Exclusions and Exceptions) (Scotland) Order 2003, failureto disclose relevant conviction(s) or pending conviction(s) will be classed as gross misconduct and will result indismissal.

Please note that:

YOU ARE THEREFORE NOT ENTITLED TO WITHHOLD INFORMATION ABOUT PREVIOUS CONVICTION(S) ONTHE GROUNDS THAT IT IS SPENT UNDER THE ABOVE ACT.

Have you ever been convicted of any crime? Yes No

If Yes, give information below.

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Court atWhich Convicted

Date ofConviction

Details ofConviction

SentenceImposed

Are there any criminal proceedings pending against you? Yes No

If Yes, give information below.

Have you ever committed any offences against children under the age of 18 and/or Protected Adults over theage of 16 or been subject to any civil proceedings where you were alleged to have committed offencesagainst children under the age of 18 and/or Protected Adults over the age of 16?

Yes NoIf Yes, give information below

Have you ever been referred for inclusion onto a Disqualified from Working with Children List and/orDisqualified from Working with Protected Adult List?

Yes No

If Yes, give information below

Date of ReferralStatus of Referral

(provisional or fully-listed)Other Relevant Details

Declaration

I declare that I have not been referred for inclusion ontoa Disqualified from Working with Children List and/orDisqualified from Working with Protected Adult List . I understand that it is a criminal offence to apply for a child care

or Protected Adult position if my name is on a Disqualified from Working with Children List and/or Disqualified fromWorking with Protected Adult List (other than listed provisionally).

I hereby consent to The Highland Council checking this information through Disclosure Scotland.

Signed: Derrick Roberts Date: 7th September 2012