Post Applied For:
Department:
Post Ref. No.:
Location:
PERSONAL DETAILS
Surname:
Preferred Title: Mr Mrs Miss Ms Dr.
Forename(s):
Address:
Postcode:Email:
Telephone Numbers Daytime:
Evening:
Mobile:
PRESENT OR LAST EMPLOYER
Name and Address of employer:
Postcode:
Type of Business:
Post held:
Date Appointed:
Date Left:
Salary:
Allowances:
Reason for leaving:
Period of notice:
Are you subject to post termination restrictions? No Yes *
EMPLOYMENT HISTORY (within last 10 years)
From (Month & Year)
To (Month & Year)
Employers name & address
Post Held and reason for leaving
ABSENCES
Please state approximate dates and lengths of any absences from work (excluding authorised holidays) in the last 12 months.
DRIVING
Do you hold a current clean driving licence?
No Yes
If no, please give details of endorsements
EDUCATION AND QUALIFICATIONS
GENERAL Names of Schools / Colleges / Other
Dates attended to/from
Qualifications/Examination subjects taken/to be taken
Result and date obtained
PROFESSIONAL
SPECIALIST COURSES
Course Organiser
Title of Course
(N.B. If short-listed you my be asked to provide proof of qualifications)
MEMBERSHIP OF PROFESSIONAL BODIES
Body:
Membership details:
Date obtained membership:
Further details:
ASYLUM AND IMMIGRATION
You will be required, if offered employment, to provide evidence of your entitlement to work in the UK.
DISCLOSURE
Criminal records will be taken into account for recruitment purposes, if the conviction is relevant to the post applied for. If you are offered the job you may be required to complete a criminal records bureau check. Failure to disclose such convictions could result in disciplinary action or dismissal.
Have you any previous convictions? No Yes
Do you agree to request a criminal records bureau check? No Yes
If, yes, please give details of the offence(s), including the date and sentence:
(NB: It is normally necessary to give details of any spent convictions.)
REFERENCES
Please give the names of two references. One should be your present or latest employer. Referees are not normally approached prior to interview. Do you wish to be notified before we approach your referees? No Yes
Referee 1
Referee 2
Name:
Occupation:
Tel No.:
Please state if you may be known by a different name, e.g. maiden name
Where did you see this job advertised? (please tick)
National Newspaper
Local Newspaper
Internet
Professional Journal
Job Centre
Other (please specify)
ADDITIONAL INFORMATION
You are invited to give here any additional information which is relevant to the application, including the nature of your present duties, relevant experience, training received, special interests, current studies. (If you have a current CV you may enclose this with your application).
The processing of your application may involve us holding sensitive information about you, such as your ethnic or racial origin for equal opportunities purposes or your physical or mental health.In order to comply with the Data Protection Act we need your specific consent to do this. To signify your consent please tick the appropriate box.
Consent given
Consent withheld
Do you wish us to retain your information for future consideration in the event of a further vacancy? No Yes
DECLARATION
I declare that all the information I have provided is true. In the event that I have provided false information I understand that if appointed I may be liable to disciplinary action including dismissal.
EQUAL OPPORTUNITIES
Please tick appropriate boxes. This information is for monitoring purposes only. It will be treated in the strictest confidence and will not be used in the selection decision or to assess suitability for the job.
Gender
Male:
Female:
Ethnic Origin:
White:
British:
Irish:
Any other white background: Please specify:
Mixed:
White & Black Cari
White & Asian
Any other mixed background: Please specify:
White & Black African
Asian or Asian British
Indian
Pakistani
Any other Asian background: Please specify:
Bangladeshi
Black or Black British
Caribbean
African
Any other Black background: Please specify:
Chinese or Other Ethnic Group
Chinese
Any other ethnic group:
Please specify:
DISABILITY
This information will enable us to comply with our duties under the Disability Discrimination Act 1995
A person who has a physical or mental impairment which has a substantial and long term adverse effect upon that person's ability to carry out normal day to day activities is regarded as disabled, e.g. arthritis, RSI, diabetes, dyslexia, epilepsy, angina, depression.
The impairments must relate to one or more of the following:
Mobility
Manual dexterity
Physical co-ordination
Continence
Speech, hearing or eyesight
Ability to lift, carry or otherwise move everyday objects
Memory or ability to concentrate, learn or understand
Do you consider yourself to be disabled?
Yes
No
If yes, please give brief details of your disability and whether you are taking medication to control it:
Please identify any special requirements which would assist you:
In the recruitment process:
To enable you to carry out the job:
