APPLICATION FORM CARIBBEAN COURT OF JUSTICE

1 APPLICATION form . CARIBBEAN COURT OF JUSTICE . POSITION APPLIED FOR: _____. NAME OF APPLICANT: _____. Page 1 of 5. Section A APPLICANTS PERSONAL DETAILS. Last/Surname/Family Name First/Given Names Current Position/Role Title Current Employer Personal Postal Address Business Postal Address Preferred Telephone Number (International Dial Code). (Number). Preferred Email Address Fax Number Nationality/Nationalities Date of Birth (DD/MM/YY). Section B EDUCATION, TRAINING, PROFESSIONAL and LEADERSHIP EXPERIENCE. (Please complete each section).

2 1. EDUCATION. Degrees/Diploma/Certificates awarded Name and Address of Educational Years Attended (List as many as relevant, add rows if Institutions needed) From To Page 2 of 5. 2. PROFESSIONAL TRAINING (Courses, Seminars, Workshops). Certificates/Diplomas awarded (List as Name and Address of Training Institutions Period of many as relevant, adding rows if Training needed). From To 3. PROFESSIONAL EXPERIENCE: Please list your last five (5) job positions starting with the most recent and indicate briefly the specific areas of the job description your experience relates to.

3 Job Position Title Organization Years Brief Experience Description From To Section C MOST RELEVANT ACHIEVEMENTS and ABILITIES. After reviewing the RESPONSIBILITIES for this position please list and outline the top three (3). achievements from your background that are most relevant to the position. (Maximum of 200 words each). Achievement 1: Achievement 2: Page 3 of 5. Achievement 3: SECTION D GENERAL. 1. CHARACTER. Have you ever been convicted of or No Yes (Please give details including dates). cautioned in relation to any criminal offence?

4 Have you ever been adjudged No Yes (Please give details including dates). bankrupt, made a composition with your creditors, or have been sued to judgement for any debt, or any such proceedings pending? Have you ever had proceedings No Yes (Please give details including dates). brought against you, or paid a penalty or made a composition in respect of failing to pay any debt or any other default relative to any other form of tax or rates or are there any such proceedings pending? Have you ever had action brought No Yes (Please give details including dates).

5 Against you for professional negligence without a matter being dismissed, or are any such proceedings pending? If any such action has been brought against your organization/employer in respect of any matter under your supervision, please answer Yes . Are you, or have you ever been No Yes (Please give details including dates). subject to disciplinary proceedings in respect of complaints regarding a matter involving you personally or under your supervision, without the matter having been dismissed, or are any such proceedings pending?

6 Page 4 of 5. 2. REFEREES: Please provide the names, positions and contact information for three (3) persons (not relatives) who you consider will be able to comment on your qualities and experience. [The Commission may write to the persons named below.]. Name of Referee Position Contact (Address, Telephone/Mobile and Email Address PART E: COMPLETION OF APPLICATION : Please sign and date your APPLICATION . Signature Date Page 5 of 5.)