Position
Applied For
Willing
to apply for DISCLOSURE to the Criminal Records Bureau
yes
no
PERSONAL
DETAILS
Full
Name
Mr
Mrs
Miss
Address
Post
Code
Telephone
Number
Mobile
Email ( THIS IS REQUIRED )
Place
of Birth
Are
you a Citizen of the EU or EEA?
yes
no
If
“ No”, do you have a Work permit?
yes
no
HEALTH
& DISABILITIES
Do
you have any disabilities which may be relevant to this Job Application:
yes
no
If
Yes, please describe them:
Are
you Registered Disabled?
yes
no
Overall
State of Health:
excellent
good
poor
Hearing:
excellent
good
poor
Eyesight:
excellent
good
poor
Do
you wear any of the following:
Spectacles
Contact Lenses
Neither
Please
give details of any medical condition for which you have received
treatment in the past 5 years:
Have
you had treatment for any condition relating to the abuse or mis-use
of drugs or alcohol within the last 5 years? yes
no
If
“YES” please provide brief details
Would
you be willing to
have a medical examination if required ? yes
no
DRIVING
RECORD
Do
you have a current clean “FULL” driving licence? yes
no
If “YES”,
for what classes of Vehicle
Driving licence
valid
from:
To:
Number
of Penalty Points (if any) endorsed on current licence:
Have
you ever been disqualified from driving, or had insurance refused?
yes
no
If “Yes”,
please provide brief details:
GENERAL
EDUCATION
Examination
results/qualifications obtained
EMPLOYMENT
Previous
Employment (Employer Name and your Job Title)
Referees
JOB
FLEXIBILITY
Prepared
to Work: Full-Time
Part-Time
Shifts
If
Part-Time please indicate preferred hours:
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 UP 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:
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 Single
Married
Separated
Widowed
Divorced
Sex
Male
Female
Ethnic
Origin African
Afro-Caribbean
Asian
European
Polynesian
Disabilities
(specify)
Registered
Disabled Number (where relevant)
DECLARATION
- please read carefully, then date and submit your application.
I
confirm that the information I have provided is correct and understand
that misleading statements may be sufficient grounds for cancelling
any agreements made. I also understand that questions left unanswered
may be discussed at interview(s) arising from this application:
Date