JOB APPLICATION FORM
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Position Applied For:- _____________________________________________________________________ PERSONAL DETAILS Full Name:-______________________________________________________________________________ Address:- ______________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Contact Telephone Number/s____________________________________________________________ Are you legally eligible for employment in the UK (if you are unsure please seek advice from Company Management:- __________________________________________________________________________
Do you have a current full driving licence?
Yes
No
Driving licence valid from:-__________________ To:- __________________ Number of Penalty Points (if any) endorsed on current licence:- ______________________ Have you ever been disqualified from driving, or had motor insurance refused? Yes No
If “Yes”, please provide brief details_________________________________________________________ A copy of your driving licence must be provided upon offer of position and any changes to be reported immediately. Please note a copy of your driving licence must be provided every 6 months along with a copy of your current car insurance (if using your own car during to make calls to service users)
EDUCATION – please continue on a separate sheet if necessary. From To Name of University, College, From To Place of Further Education i.e. training establishment
Name of University, College, Place of Further Education i.e. training establishment
Examination results/qualifications obtained please detail any qualifications/certificates you hold along with the date obtained you feel may be relevant to the position applied for.
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EMPLOYMENT HISTORY Name and Address of Current Employer (or last Employer if currently unemployed) Job Title and Main Duties Employment Dates From To
Average gross pay: £ per hour/week/month Previous Employment (Employer Name, Address and your Job Title and dates of employment) for a Minimum of 10 years please continue on a blank sheet if necessary, ensure any gaps in employment history are explained. 1. From To
Reason for Wanting to Leave/Leaving:
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Notes to explain gaps in employment history (please continue on a blank sheet if necessary):_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________
JOB FLEXIBILITY Prepared to Work: Full-Time Part-Time Details of any other work which you will continue to undertake if you are offered this Job Position: Please provide details of any outstanding holidays to be taken:
Available to take employment from:-
REHABILITATION OF OFFENDERS ACT, 1974 Through the 1975 exemptions Order of the Rehabilitation of Offenders Act, 1974, and by virtue of the nature of the post for which you are applying, we are obliged, as your prospective employers, to ask the following question. Any information supplied by yourself will remain confidential and considered only in relation to the Job Application: With the exception of minor motoring offences, have you ever been convicted of any criminal offence by a Court of Law? YES NO If “YES” please provide brief details of the offence(s) and relevant dates:
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……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… All positions are subject to a Criminal Records Bureau checks (Enhanced)
EQUAL OPPORTUNITIES – VOLUNTARY INFORMATION The organisation seeks to recruit employees on the basis of their general suitability for a position and aims to ensure that consideration of age, sex, marital status, disability and racial or ethnic origin should play no part in this process. In order to monitor the effectiveness of this commitment to equal opportunities it would be helpful if you could complete this section of the form. Completion is not compulsory but should you give details below the information will be used for no other purpose than that as stated in this paragraph. Marital Status Sex Ethnic Origin Single Male African Married Female Afro-Caribbean Mixed Race Asian European Separated Widowed Divorced
References :We will require at least two written references, from people you are not related to, one of which must be your current or most recent employer:Reference One:Name of Referee :Position:Company Name:Company Address:______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________
References :Reference Two:Name of Referee :______________________________________
Position:______________________________________ DECLARATION - please read carefully ensuring 10 year employment history is complete and any gaps explained in full, then sign and date your application: Company Name:______________________________________ I certify that to the best of my knowledge, the information in this application form is correct and complete. I agree Address:- ______________________________________ Companythat any deliberate omissions, misrepresentations or falsification of the information in this ______________________________________ ______________________________________
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application form will be grounds for the application to be rejected, or possibility of subsequent discharge once employed by the Company. I understand that if employed by the Company this form may be filed on computer and/or in manual records and will be made available to visiting inspectors as necessary. Applicant’s signature:- _______________________________________ Date:________________________________________
Office Use:-
Medical History Has your employment ever been terminated on the grounds of ill health? Approximately how many days sickness have you had in the past 12 months? What is your height? What is your weight? What is your weekly alcohol consumption? Do you smoke? Are you currently taking any prescribed medicine? Are you currently under the care of a doctor or other medical professional?
YES
NO
Are you currently suffering from of have suffered from, any of the illnesses listed:Lung Disease YES NO Heart/circulatory illness/hyperventilation YES NO Diabetes YES NO Asthma YES NO Hayfever/allergies YES NO Bronchitis/Pneumonia/Pleurisy YES NO Tuberculosis YES NO Epilepsy/Frequent fainting/blackouts YES NO
JOB APPLICATION FORM
Headaches Migraines Psychiatric illness/anxiety/depression Dermatitis/skin sensitivity Back/neck problems Recurrent Infections Hepatitis/jaundice Stomach/bowel trouble Joint problems Severe stress reaction Depression/anxiety High blood pressure Hernia or rupture Kidney/bladder problems Hearing/sight problems Mobility problems Serious accident YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO
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If you have answered “YES” to any questions in this section, please give details and dates where relevant; this is important, especially where you have a qualifying disability under the Disability Discrimination Act 1995, as it will enable us to identify what, if any “reasonable adjustments” need/can be made.
I hereby declare that the information given within the medical history section is full and true to the best of my knowledge. I understand that if, later, it is discovered that I have knowingly withheld medical information, disciplinary action may be taken against me, which may include dismissal. Signature: ____________________________________________ Date: ____________________________________________