ICP application form 1. Personal information Surname * First name(s) * Preferred name Title Dr Mr Mrs Miss Ms Other Other, please state Address * Postcode * Preferred telephone number * How many years have you been a customer of Longhurst Group? * Supporting questions Why do you want to become a member of the Independent Complaints Panel? * How would your involvement benefit you and the panel? * From reading the role description what skills and experience would you bring to the panel? * Would you be willing to take part in training to increase your skills and knowledge? * Yes No Do you have any particular support needs we need to cater for? * Any additional comments to support your application. 6. Declaration Are you known or related to any staff member, Director or Board Member of the Longhurst Group? * Yes No If yes, please tell us more details. Are you a Board Member or staff member of another housing provider? * Yes No If yes, please tell us more 7. Consent The information which you’ve given us will be processed and held on computer. It will only be used for recruitment and selection purposes. I confirm that to the best of my knowledge the information contained on this form is accurate. *
