Confidential Personal Data Form This form is confidential when completed
Please answer ALL questions -if an entry is not applicable insert ‘NO’ or ‘N/A’ Typically, this form is used to assist NSI in determining the repute and experience of management.

Section 1 Personal information
Title (optional)
All forenames
Surname (family name)
Do you hold an SIA licence?	Yes	No	If Yes, state licence number

Section 2 Current employment
Name of company
Address
Post code	Your office email
Tel no	Fax no
Current job title	Reporting to
Date employment commenced (dd/mm/yyyy)	Date security screening completed (dd/mm/yyyy)

Section 3 Qualifications and industry experience
List Vocational, Trade, Apprenticeship or Professional Qualifications
Total relevant experience in activity for which application is being made	years	months
Total relevant senior management experience (if any) in activity for which application is made	years	months

Section 4 Company directorships
List ALL company directorships. Continue on a separate sheet if necessary.
4.1 Directorship held	Dates
Company name	From (dd/mm/yyyy)
Company Registration No.	To (dd/mm/yyyy)
4.1 Directorship held	Dates
Company name	From (dd/mm/yyyy)
Company Registration No.	To (dd/mm/yyyy)
4.3 Directorship held	Dates
Company name	From (dd/mm/yyyy)
Company Registration No.	To (dd/mm/yyyy)

Section 5 Employment record
List ALL periods of employment over the last 10 years, however brief: Including self-employment and unemployment in date sequence If you were registered unemployed for any reason or period, show area of the unemployment benefit If you were self-employed state name of the business and the registered address Start with your most recent employment and work backwards Continue on a separate sheet if necessary.
Period of employment, unemployment or self-employment
5.1 Date from (mm/yyyy)	Date to (mm/yyyy)
Employment status	Employed	Self-employed	Unemployed
Company name
Address
Post code	Telephone number
Position held	Reporting to
Reason for leaving
5.2 Date from (mm/yyyy)	Date to (mm/yyyy)
Employment status	Employed	Self-employed	Unemployed
Company name
Address
Post code	Telephone number
Position held	Reporting to
Reason for leaving
5.3 Date from (mm/yyyy)	Date to (mm/yyyy)
Employment status	Employed	Self-employed	Unemployed
Company name
Address
Post code	Telephone number
Position held	Reporting to
Reason for leaving
5.4 Date from (mm/yyyy)	Date to (mm/yyyy)
Employment status	Employed	Self-employed	Unemployed
Company name
Address
Post code	Telephone number
Position held	Reporting to
Reason for leaving

Section 6 Background information
Please answer Yes or No to all the following questions. If the answer is Yes, then please give details with dates in the space below each box. Continue on a separate sheet if necessary.
6.1 Have you (or a member of your household, if they have any involvement or influence on the business) ever been cautioned, fined, sentenced to imprisonment, placed on probation, discharged on payment of costs, adjudged bankrupt, or had any order made against you or him/her by a criminal, civil or military court or public authority or are there any pending actions against you or him/her?
6.2 Have you ever been dismissed (for misconduct or any other reason) by an employer?
6.3 Have you (or a member of your household, if they have any involvement or influence on the business) at any time during the last seven years, been a shareholder (with shareholding of 10% or more), director or senior manager of a company that during the time that you/they were a shareholder (with shareholding of 10% or more), director or senior manager or to your knowledge or belief within twelve months of that time: had an Administrator or Administrative Receiver appointed over any of the company's undertaking or property; had a Receiving Order made against the company; went into liquidation; was the subject of an application to a Court for a winding-up order; entered into a "Company Voluntary Arrangement" with its creditors, or in any other way compounded with its creditors or had any distress or execution levied against any of the property or assets of the company?
6.4 Have you (or a member of your household, if they have any involvement or influence on the business) at any time during the last seven years entered into an "Individual Voluntary Arrangement" or into a "Partnership Voluntary Arrangement" with your/their creditors?
6.5 Have you (or a member of your household, if they have any involvement or influence on the business) ever been disqualified in law (e.g. under the Companies Act, the Insolvency Act or the Company Directors Disqualification Act) from being a director of a company or from being employed in the management of a company or other business?
6.6 Are you aware of any other material facts about you (or any of your family or member of your household, if they have any involvement or influence on the business) regarding character, repute, honesty or personal history which might be regarded as affecting your personal standing as a demonstrably reputable person of good standing or your suitability for employment within the fire/security industries?

Section 7 Declaration
For the purposes of compliance with current data protection legislation, I acknowledge and certify as follows:
7.1 I have completed this form myself and all the information is correct.
7.2 I acknowledge that the information and data set out in this form is required by NSI in connection with and for the purposes of the appraisal by NSI for an application for approval or continuation of approval.
7.3 I consent to the processing by NSI of the information and data contained in this form as needed to progress the application process or maintain an approval.
7.4 I agree that NSI may make any enquires in relation to this information and data for the purposes of verifying it.
7.5 I consent to NSI disclosing the information and data contained in this form when necessary for the purposes of gaining / maintaining approval(s) with NSI, or where this information and data is required by an organisation which NSI believes has a legitimate need for it. For more information about how NSI processes data and the lawful bases for processing, please refer to the NSI Privacy Notice on the NSI website.
Signature	Name in full	Date
Click here to enter a date.

Please submit applications by email to applications@nsi.org.uk or your NSI Head Office contact