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                                                               For official use only:

                                                               Date sent out:

                                                               Application No:

                                                               Date returned:

                                                               Shortlisted:                 Yes / No

APPLICATION FORM                                               Appointed:                   Yes / No
for employment

Please write in block letters using black ink, or type.

Personal Details
Title:                                First names:                                   Surname and suffix, if any:

Are you, or have you, ever been known by any other name? If so, what:


Email:                                                        National Insurance No:

Telephone (w):                             Telephone (h):                              Telephone (m):

The information given on this application form is correct to the best of my knowledge and belief.

I understand that any false statement may be sufficient cause for rejection or, if employed, dismissal.

Signature __________________________________________                          Date     ___________________________

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                                                           Application No:
                                                           [official use only]

Please supply the names and addresses of two referees. Preferably, one should be related to your current or recent
employment and one should have known you for a minimum of five years [family members and people who live with
you are not accepted]. References will normally be obtained after the interview process.

Name:                                                          Name:

Job Title:                                                     Job Title:

Company:                                                       Company:

Address:                                                       Address:

Telephone:                                                     Telephone:

Email:                                                         Email:

Educational Qualifications
What academic qualifications do you hold?
If shortlisted, you should be prepared to provide proof of any qualifications.
                  Dates                     Name of school, college and/or       Major subjects studied, examinations
                                                       university                       taken and test results
      From                  To

What training have you undertaken?
If shortlisted, you should be prepared to provide proof of any qualifications.
                  Dates                            Organising Body                Subject/Course taken and results
      From                  To

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Current job summary
Employer [name and address]:

Type of business:                                           No of employees:

Job Title [and grade, if applicable]

Reporting to [job title]:

Date of appointment:                                        Current base salary:

Other benefits:                                             Reason for leaving:

Period of notice:                                           Dates unavailable for interview:

Previous Posts
Please give details of your employment history up to your present job:
  Date      Date left       Name, location and business of               Job               Final   Reason for
 started                              employer                                            salary    leaving
  [m/y]      [m/y]

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Current Job Details
Please describe your present or most recent job. What do you consider to have been your major contributions in this
job and why? What are your main responsibilities? Attach copies of job description if helpful.

Why do you wish to change?
What attracts you to this new job in particular?

How do you spend your time?
What is important to you outside your work?

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Please read the notes below before completing this form. Guidance notes are also enclosed to help you.
 Give details of the relevant skills, experience and knowledge you possess that demonstrate how you meet all of
    the shortlisting requirements shown in the person specification at the back of the job description.
 Number your answers to match the numbering on the person specification.
 Important: Please note that information on attached CVs will be detached from the application form and will not
    be taken into account in the shortlisting process. The decision to shortlist you for interview will be based on the
    information you provide on this form.
Please use a continuation sheet on this section if necessary.

Are there any other facts, activities or connections which you feel might be raised in the future about your suitability to
hold this appointment; for instance because they could be presented as a conflict of interest? These may include
issues such as personal relationships or membership of organisations.

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Additional Information
Do you hold a current full, clean driving licence?

Do you need a work permit?

Rehabilitation of Offenders Act
Age Concern Birmingham recognises that it has a duty to its clients and the wider community to take account of
offences that may have a direct bearing on a candidate’s suitability to be an employee. The exemptions order of the
above Act allows us to enquire into the criminal background of job applicants. You should list all criminal convictions,
including any which may, in other circumstances, be considered spent. Failure to disclose any previous convictions
could result in dismissal should it be subsequently discovered. This information will be treated confidentially.

Have you ever been convicted of any criminal offence by a court of law?                       Yes / No

If yes, please complete the section below:

Date                    Place                        Offence                       Sentence

  Please return your completed Application Form along with the Equal Opportunities Form

                                                Human Resources
                                             Age Concern Birmingham
                                                 Coleshill House
                                                75 Coleshill Street
                                                 Sutton Coldfield
                                                     B72 1SH

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for employment applications

Application for post of: ______________   ______________________________

Where did you hear about this opportunity? [Publication etc]

Date of birth: _________________________________________________

Age: _______________________________________________________

This information is to develop Age Concern Birmingham’s Diversity & Equality Policy and is used only for
monitoring purposes.

It will be separated from your application upon receipt and will not be available to those undertaking
shortlisting or interviewing.

What is your ethnic group?
Choose ONE section from A to E, then tick the appropriate box to indicate your cultural

A.     White
              British
              Irish
              Any other White background, please state: ______________________________

B.     Mixed
              White and Black Caribbean
              White and Black African
              White and Asian
              Any other Mixed background, please state: _____________________________

C.     Asian or Asian British
              Indian
              Pakistani
              Bangladeshi
              Any other Asian background, please state: ______________________________

D.     Black or Black British
              Caribbean
              African
              Any other Black background, please state: ______________________________

E.     Chinese or other ethnic group
              Chinese
              Any other, please state: ______________________________________________

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      Are you ….                                    Male        or       Female?

      Do you have children/other dependants?       Yes                   No

      Do you consider yourself to be disabled as
      defined by the Equality Act [previously by    Yes                  No
      the Disability Discrimination Act]?

      The Equality Act defines disability as:
       A physical or mental impairment which has a substantial and long term adverse effect
                   on a person’s ability to carry out normal day to day activities.

Thank you for your co-operation.

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