Autumn 2016-17 Tutor Personal Informtion Form
Date of Birth:
NationaI Insurance Number
If you do not yet have an NI number, please type 'Applying' into the box
Do you drive?
Do you have your own transport?
Please enter in the format xx-xx-xx
Registered Doctor's Name
Registered Doctor's Telephone Number
Registered Doctor's Address
Please detail any allergies or dietary restrictions you may have:
Please detail any long-term medical conditions such as Asthma, Diabetes, or heart problems:
Please detail any treatment or medication you are currently receiving and the reason for this:
Next of Kin
Telephone (or Mobile) Number
May we contact them in an emergency?
HMRC Present Circumstances
The answers in this section will determine the tax code that we submit to HMRC for your pay. Each of the below options corresponds to a different code (not seen here). If you know what your tax code is, please select "I know my tax code" and then enter it in the field that appears
Which of the following statements applies to you
A - This is my first job since last 6 April and I have not been receiving taxable Jobseeker's Allowance, Employment and Support Allowance, taxable Incapacity Benefit, State or Occupational Pension.
B - This is now my only job but since last 6 April I have had another job, or received taxable Jobseeker's Allowance, Employment and Support Allowance or taxable Incapacity Benefit. I do not receive a State or Occupational Pension.
C - I have another job or receive a state or occupational pension.
I know my tax code
Please enter your tax code
If you enter a code, please note that it should be no longer than 5 characters
Criminal Convictions Declaration
To work with The Brilliant Club, you will need Enhanced DBS Clearance (Disclosure Barring Service) before you will be
allowed into any schools to complete your tutorials. Please answer the following questions to help us with this process.
a) Have you ever been convicted of a criminal offence?
b) Do you have a court appearance pending or have you been charged by the Police for a Criminal offence in the last 5 years?
If you answered YES to A or B above, please supply details of each offence (Date/Court/Offence/Sentence) - Police Act
1997 (Criminal Record Certificates: Relevant Matters (England and Wales) Order 2013 (“the Order”).
NB: Having a criminal conviction will not automatically discount you from working with The Brilliant Club however,
acceptance will be at the discretion of The Brilliant Club, the participating school and dependant on the conviction.
I hereby verify that the information I have provided above is correct to the best of my knowledge
Signed (Please enter full name)
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