Pre-employment Health Screening by HC120614011631

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									     BF-HR-001                                         IMPORTANT
     Issue 1
                                                       Check the Intranet to ensure you are using the latest issue of this Form


     Amphenol
     Amphenol Limited

     Human Resources
     Thanet Way
     Whitstable
     Kent CT5 3JF

     Tel: 01227 773263
     Fax: 01227 263028

                             APPLICATION FOR EMPLOYMENT
     Please type or complete in black ink

     1.           Position Applied for:


     2.           Personal Details:
                  Title: (Mr., Mrs., Miss., Ms)                             Forenames:                                                Previous Surname (if applicable):


                  Surname:


                  Address:                                                                                                            Telephone No:

                                                                                                                                      Mobile No:
                                                                                                                                              (If work number given, discretion will be exercised)

                                                                            Postcode:                                                 Work No:
                  Place of Birth:

                  National Insurance Number:                                                           Nationality:

                  Emergency Contact Name:                                                                          Relationship to You:
                  Address:


                                                                                                                   Telephone No:
                  Do you hold a current driving licence:                      Yes/No

                  If yes, what type                Provisional                 Full               HGV                 Motorcycle


     2(a)         Have you a relative or friend employed by Amphenol Ltd:                              Yes/No

                  If so state name, relationship and department:


     2(b)         Have you previously worked for Amphenol:                                             Yes/No

                  If yes, when:                                                                        Position and Department


                  Are you prepared to work shifts                                                      Yes/No
     2(c)         What period of notice does your present Employer expect you to give:




This document, if printed is for information only, it is the users responsibility to ensure use to latest revision available on the intranet. The contents of this document remain the property of
Amphenol Ltd. This document contains confidential proprietary information, and shall not be copied, disclosed, reproduced or used for any other purpose; unless written permission is granted by
Amphenol Ltd. Amphenol Ltd retains the right to request the prompt return of this document.
     BF-HR-001                                         IMPORTANT
     Issue 1
                                                       Check the Intranet to ensure you are using the latest issue of this Form

     3(a)         Education
                                                                                      Full or                Dates
                        Schools/College/University                                                                                        Examinations (subjects/results)
                                                                                     Part-time           From      To




     3(b)         Qualifications & Professional Institutions:
                  List degrees, diplomas or certificates held and when awarded. If a member of a any Professional Body or Institute, please
                  give details, status of membership and date of election
                                                         Details                                                       Date




     3(c)         Appointments:
                  List civil appointments, honours, awards, industry and trade representation, voluntary organisations, social and sports clubs.
                                                                                                                Office/Appointment Held
                                                     Organisation
                                                                                                                     Honour/Award




     3(d)         Apprenticeship or Equivalent Training, if any
                               Company                                                   Trade or Profession                                                 Dates




     Please state any other experience, qualifications, skills or special training which you consider might be useful in support of your
     application:




This document, if printed is for information only, it is the users responsibility to ensure use to latest revision available on the intranet. The contents of this document remain the property of
Amphenol Ltd. This document contains confidential proprietary information, and shall not be copied, disclosed, reproduced or used for any other purpose; unless written permission is granted by
Amphenol Ltd. Amphenol Ltd retains the right to request the prompt return of this document.
     BF-HR-001                                         IMPORTANT
     Issue 1
                                                       Check the Intranet to ensure you are using the latest issue of this Form


     4.          Service in H.M. Forces:
                 Dates. From: ………………….. to: ……………. Branch of Service: …………… Rank at Discharge: ………………………

                 List duties and any special training or experience: ……………………………………………………………………………….
                 …………………………………………………………………………………………………………………………………….
                 …………………………………………………………………………………………………………………………………….



     5.           Languages:
                  Give details of languages spoken and degree of fluency.
                                  Language                            Speak                                                      Read                                  Write




     6.           Employment Record:
                  Please include details of your most recent employment starting with present or most recent – continue on separate sheet if
                  necessary. If applying for your first job since leaving school please use Section 7 to indicate any work experience completed,
                  voluntary work completed or any positions of responsibility held at school or college.

                  Present / Previous Employer: …………………………………………………………………………………………………….

                  Nature of business: ………………………………………………………………………………………………………………

                  Address: ……………………………………………………………………….…………………………………………………
                  Start date: …………………………………………………                                                    Finish Date (if applicable): ……………………………………

                  Starting salary: …………………….. per …………………. Current/finishing salary: ………………… per …………………

                  State job title: - ……………………………………………………………………………………………………………………

                  State main duties/responsibilities: - ………………………………………………………………………………………………

                  ……………………………………………………………………………………………………………………………………

                  ……………………………………………………………………………………………………………………………………

                  Period of notice required: ………….…….…. Why do you wish to change employment: …………………………………….

                  ……………………………………………………………………………………………………………………………………

                  Previous employer: ………………………………………………………………………………………………………………

                  Nature of business: ………………………………………………………………………………………………………………

                  Address: ………………………………………………………………………………………………………………………….
                  Start Date: …………………………………………………… Finish date: .………………………….…………………………

                  Starting salary: …………………….. per …………………. Current/finishing salary: ………………… per …………………

                  State job title: - ……………………………………………………………………………………………………………………

                  State main duties/responsibilities: - ………………………………………………………………………………………………

                  ……………………………………………………………………………………………………………………………………

                  ……………………………………………………………………………………………………………………………………

                  Reason for Leaving: ………………………..…………………………………………………………………………………..

                  ……………………………………………………………………………………………………………………………………



This document, if printed is for information only, it is the users responsibility to ensure use to latest revision available on the intranet. The contents of this document remain the property of
Amphenol Ltd. This document contains confidential proprietary information, and shall not be copied, disclosed, reproduced or used for any other purpose; unless written permission is granted by
Amphenol Ltd. Amphenol Ltd retains the right to request the prompt return of this document.
     BF-HR-001                                         IMPORTANT
     Issue 1
                                                       Check the Intranet to ensure you are using the latest issue of this Form



                  Previous employer: ………………………………………………………………………………………………………………

                  Nature of business: ………………………………………………………………………………………………………………

                  Address: ………………………………………………………………………………………………………………………….
                  Start Date: …………………………………………………. Finish date: ……...……………………………………………….

                  Starting salary: …………………….. per …………………. \finishing salary: ………………… per ………………………….

                  State job title: - ……………………………………………………………………………………………………………………

                  State main duties/responsibilities: - ………………………………………………………………………………………………

                  ……………………………………………………………………………………………………………………………………

                  ……………………………………………………………………………………………………………………………………

                  Reason for Leaving: …………………….………………………………………………………………………………………

                  ……………………………………………………………………………………………………………………………………

                  Previous employer: ……………………………………………………………………………………………………………….

                  Nature of business: ……………………………………………………………………………………………………………….
                  Address: …………………………………………………………………………………………………………………………..
                  Start Date: ……………………………………………….. Finish date: ……………………………………………………….

                  Starting salary: …………………….. per …………………. Finishing salary: ………………… per …………………………..

                  State job title: - ……………………………………………………………………………………………………………………

                  State main duties/responsibilities: - …...………………………………………………………………………………………….

                  …………………………………………………………………………………………………………………………………….

                  …………………………………………………………………………………………………………………………………….

                  Reason for Leaving: ……………………………………………………………………………………………………………..

                  …………………………………………………………………………………………………………………………………….


                  Previous employer: ……………………………………………………………………………………………………………….

                  Nature of business: ……………………………………………………………………………………………………………….


                  Address: …………………………………………………………………………………………………………………………..

                  Start Date: ……………………………………………….. Finish date: ……………………………………………………….

                  Starting salary: …………………….. per …………………. Finishing salary: ………………… per …………………………..

                  State job title: - ……………………………………………………………………………………………………………………

                  State main duties/responsibilities: - …...………………………………………………………………………………………….

                  …………………………………………………………………………………………………………………………………….

                  …………………………………………………………………………………………………………………………………….

                  Reason for Leaving: ……………………………………………………………………………………………………………..

                  …………………………………………………………………………………………………………………………………….




This document, if printed is for information only, it is the users responsibility to ensure use to latest revision available on the intranet. The contents of this document remain the property of
Amphenol Ltd. This document contains confidential proprietary information, and shall not be copied, disclosed, reproduced or used for any other purpose; unless written permission is granted by
Amphenol Ltd. Amphenol Ltd retains the right to request the prompt return of this document.
     BF-HR-001                                         IMPORTANT
     Issue 1
                                                       Check the Intranet to ensure you are using the latest issue of this Form

     7.           Additional Information:
                  Please state any other experience, qualifications, skills or training which you consider might be useful in support of your
                  application:




     8.           Interests/hobbies:
                  Give details of pastimes, sports, etc.




     9.           Referees:
                  All offers of employment are subject to the receipt of satisfactory references. Please give the names and address of two
                  referees (not members of your family), one of whom must be a previous employer: (NB: References will not be taken up with
                  present employer without prior agreement)
                  Name: …………………………………………………….                                                         Name: …………………………………………………….

                  Address: ………………………………………………….                                                       Address: ………………………………………………….

                  ……………………………………………………………                                                             ……………………………………………………………

                  ……………………………………………………………                                                             ……………………………………………………………

                  Occupation: ……………………………….……………..                                                    Occupation: ……………………………….……………..

                  Tel No: …………………………………………………..                                                       Tel No: …………………………………………………..


     10.          Declaration:

                  I confirm that the information given on this form is, to the best of my knowledge, true and complete. Any false statement
                  may be sufficient cause for rejection or, if employed, dismissal. In signing this document I also agreed to Amphenol Ltd
                  processing and retaining my personal details for the purpose of recruitment and employment in accordance with the Data
                  Protection Act.
                  Amphenol Ltd is an equal opportunities employer.




                  Signature: …………………………………………………….. Date: ……………………………………………………….




This document, if printed is for information only, it is the users responsibility to ensure use to latest revision available on the intranet. The contents of this document remain the property of
Amphenol Ltd. This document contains confidential proprietary information, and shall not be copied, disclosed, reproduced or used for any other purpose; unless written permission is granted by
Amphenol Ltd. Amphenol Ltd retains the right to request the prompt return of this document.
     BF-HR-001                                         IMPORTANT
     Issue 1
                                                       Check the Intranet to ensure you are using the latest issue of this Form




                    EQUAL OPPORTUNITIES MONITORING
                            QUESTIONNAIRE
     The following information is required solely for recruitment monitoring purposes and will be treated
     in the strictest confidence. It will not be used in shortlisting or appointing a post.

     We would appreciate it if you could complete and return this form to us at your earliest convenience,
     however, please note that it is voluntary.

     1.           Position Applied for:


     2.           Personal Details:
                  Date of Birth:                                            Sex (M/F):                 Place of Birth:

                  Nationality:


     3.           Ethnic Origin (please tick the correct box):

                  White: British                  Irish

                  Mixed Heritage: White/Black Caribbean                         White/Black African                 White/Asian

                  Black or Black British: Caribbean                         Africa
                  Asian or Asian British: Indian                         Pakistani            Bangladeshi
                  Chinese: Chinese
                  Other – please specify:




     4.           Do you consider yourself to have a disability?                        Yes                 No

                  The Disability Discrimination Act defines disability as ‘a physical or mental impairment which has a substantial and long
                  term effect on the person’s effect on the person’s ability to carry out normal day-to-day activities’.

                  If you are a Registered Disabled Person, please provide the following information:

                  Certificate No: ……………………………………………………                                                         Date of Expiry: …………………………………………


     5.           Where did you hear about this vacancy?

                  Word of Mouth                     Internal Advert                    Jobs in Kent                     Monster                 Company Website

                  Newspaper (Please specify): … ………………………………………………………………………………………………….

                  Recruitment Agency (please specify):                    ………………………………………………………………………………………..

                  Other (please specify):             …………………………………………………………………………………………………….....




This document, if printed is for information only, it is the users responsibility to ensure use to latest revision available on the intranet. The contents of this document remain the property of
Amphenol Ltd. This document contains confidential proprietary information, and shall not be copied, disclosed, reproduced or used for any other purpose; unless written permission is granted by
Amphenol Ltd. Amphenol Ltd retains the right to request the prompt return of this document.

								
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