CVC Application Contact DetailsTitleMrMrsMissMsDrOtherTitle Other First Name(s) Surname Correspondence Address Postcode Home Telephone Mobile Telephone Work Telephone Email Date of birth DD slash MM slash YYYY About YouCurrent Occupation Skills/Knowledge & ExperienceMembership of organisation/body within MonmouthshireSupporting StatementOur Values - Open | Fair | Flexible | AchievingAre you a tenant of MHA?* Yes No Are you a leaseholder of MHA?* Yes No Are you complying with the terms of your tenancy/lease?* Yes No Are you a Monmouthshire County Councillor?* Yes No Are you an officer of Monmouthshire County Council?* Yes No (if you are an employee but do not work in housing or a managerial role please answer ‘No’)Are you a member of the community* Yes No Are you involved in the management of a profit making business that is or may wish to do business with MHA?* Yes No Are you a self-employed person who is likely to seek work from MHA?* Yes No Do any of the above descriptions in this section apply to close relations?* Yes No If 'yes', please give details Have you been a director of any business which has gone into insolvent liquidation?* Yes No Have you been convicted of any criminal offences (including driving offences) other than those regarded as spent under the Rehabilitation of Offenders Act 1974?* Yes No If you have answered ‘yes’ to any of the above statements please provide details:Unfortunately, if you answer ‘yes’ to any of the following statements you become ineligible to apply for thisposition. Someone who is or becomes bankrupt or who makes a voluntary arrangement with creditors. Someone who is or may be suffering from mental disorder (as defined in Section 1 of The Mental HealthAct 1983), and either: is admitted to hospital, or has a court order made relating to the illness to appoint someone to look after their property orother affairs in the opinion of the registered medical practitioner he/she is suffering from a mental disorder byreason of which he/she is incapable of carrying out the duties of a Committee Member Someone who is disqualified from acting as a director of a company for any reason. Someone who has been removed from the Board/Committee of the Association or of any otherhousing association by the Welsh Government, the Housing Corporation or Communities Scotland. Someone who has been convicted of an indictable offence within the last 5 years or A tenant/leaseholder who is in a material or serious breach of his/her obligations as a tenant/leaseholder. Have you read the ‘Eligibility’ statements above and answered ‘yes’ to any of the statements detailed?* Yes No Confirmation I confirm that the information I have given on this form in support of my application is correct. I understand that the information I have given will be used by Monmouthshire Housing Association solely for the purposes for which it has been intended and may be entered onto a computer system or recorded in any form considered appropriate by the Association. I understand that under the terms and conditions of the Data Protection Act this information will be treated in a secure and confidential manner.Name* Date* DD slash MM slash YYYY Please call 01495 761104 If you wish to discuss the position further or have any concerns or queries.How did you hear about this opportunity?WebsiteFacebookTwitterIn It Together MagazineMember of MHA staffConsent I agree to the privacy policy.CAPTCHA
