Governor Nomination Form

CONFIDENTIAL E-ACT SELF-NOMINATION FORM Application for appointment as an E-ACT Governor.

1. Please enter either the name of the Local Governing Body for which you are applying or the academy/ area where you wish to be a Governor.

2. Personal Information Title Name Address

Post Code Tel: Email:

3. Statement by Applicant (Please attach CV if preferable)

4. Reference Details Please provide the name and address of a person who can provide a reference for you. This can be a business or personal reference and they must have known you for at least two years.

Name: Address: Tel: Email (if known):

5. How did you learn about being a Governor? (Please tick) Newspaper

Other Advertising

From a friend

Approached Other (Please by a Governor/ state) Sponsor

6. Signature of applicant, unless sending by email Signature:

Note – before taking up appointment, any person nominated will be required to sign a declaration stating that they have not been disqualified from membership of a Governing Body for reasons set out in School Governance Regulations. These cover disqualification for reasons of bankruptcy and criminal convictions where a term of imprisonment has been imposed without the option of a fine. Checks will be made on applicants approved for appointment to confirm that they are not deemed unsuitable to have access to children and young people under the Criminal Justices and Court Services Act 2000.

Please return your nomination form to: Governance.Enquiry@E-ACT.org.uk Or by post to: Samantha Roberts, Deputy Director for Governance & Values E-ACT, 3rd Floor, 10 Whitfield Street, London, W1T 2RE