PERSONAL DETAILS
Title: 
Mr Miss Mrs Dr  Other   
 
Surname:  
First Name:  
D.O.B(optinal):
  Marital Status:
       
Nationality:
  NI Number:
       
Address:  
 
 
Postcode:    
Mobile:    
Contact Tel:           
Email:  
 
     
  PASSPORT DETAILS  
 
Passport No:  
Place of Issue:  
Issue Date:  
Expiry Date:  
If student, please provide the course details:  
 
     
     
 
NEXT OF KIN
Name:
Relationship:
Address:
Tel:
Mob:
Email:
 
     
 
EDUCATIONAL QUALIFICATIONS
Place Of Study Qualification Date Of Qualified Add Row Remove Row
 
  TRAINING  
 
Cource Name Date Attended Expiry Date Details(If Necessary) Add Row Remove
 
  WORK EXPERIENCE  
 
From To Name Of Employer Type Of Business Job Title Add Row Remove
 
     
 
REFERENCE
Plese give the name and contact details of two referees. One should be your previous Employer.
Name:    
Job Title:    
Relationship:    
Address:

 
Company Name: :  
Tel:    
Email:    
Reference 2:      
Name:    
Job Title:    
Relationship:    
Address:    
Company Name    
Tel:    
Email:    
 
     
 
EQUAL OPPORTUNITY MONITORING FORM
The information on this form will be used in total confidence and accordance with current data protection legislation. It will help to ensure that the company proprty monitors and confirms with its policies relating to equality of opportunity. Information will be used for monitoring only. Our commitment aims to allow our staff to develop their skills and realize their maximum potential as individuals without any wish on the part of the company to limit their opportunity.
PLEASE TICK THE RELEVANT BOX.          
White   Mixed Asian Black Chinese Other
Gender:           Male     Female  
Please Indicate your age range by ticking one of the boxes below :
16-21   22-25   26-30   31-35   41-50   51-60   61-65    
Do you consider yourself to have a disability of some kind ?
Yes   No
If Yes, give details
 
 
 
                                     
 
PROTECTION OF CHILDREN AND VULNERABLE ADULTS DECLARATION
Has any Social Service Department orHas any Social Service Department or Police Service ever Conducted an equiry or investigation into any allegations or that you may pose an actual or potential risk to children or vulnerable adults?    
Yes No      
Have you ever been convicted of any offence relating to children or vulnerable adults?    
Yes No    
Have you ever been the subject of any disciplinary procedure or been asked to leave employment or voluntary activity due to inappropriate behaviour towards a child or vulnerable adult?    
Yes No    
If yes to any of these questions above, please give details.
 
     
 
REHABILITATION OF OFFENDERS
Because of the nature of the work for which you are applying, this post is exempt from the provisions of section 4(2) of the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitation of Offenders Act 1974(Exemptions) Order 1975. Applicants are therefore not entitled to withhold information about convictions, which for other purposes are spent under the provisions of act and in the event of employment any failure to disclose such convictions could result in dismissal or disciplinary action by the employer. All Successfull candidates will be required to obtain an enhanced disclosure report from the Disclosure and Barring Service.Have you ever been convicted of a criminal offence, or been subject to any confidential discharge, bind overs or caution.
Yes            No  
If Yes please give details
   Any information contained in this will be treated in confidence. Failure to disclose any relevant information or providing false or inaccurate information may be regarded as a breach of any subsequent contract of employment, resulting in disciplinary action and/or dismissal.
 
     
 
HEALTH CHECK QUESTIONNAIRE (optional/to be filled upon selection)
GP Contact Details:  
 
Please answer all the following questions by giving relevant details
 1.Have you ever suffered from any of the following:
a) Depression,anxiety state,nervous illness or breakdown    
No if Yes,    
b) Epilepsy or disease of the nervous system    
No if Yes,    
c) Ailment of lungs or chest    
No if Yes,    
d) Spinal problem(backache)    
No if Yes,    
e) Arthritis, Rheumatism or Gout etc    
No if Yes,    
f) Any heart or circulatory, including blood problems    
No if Yes,    
g) Illness of the kidneys, bladder,liver or glands    
No if Yes,    
h) Diabetes    
No if Yes,    
i) Skin disorder    
No if Yes,    
 
2. Are you presently taking medication or undergoing treatment. If so give details:
3. What is your average daily consumption of:    
Alcohol   Tobacco    
4. Are you a registered person?    
No Yes    
5. Details of any industrial disablement benefit received:
6. How many working days have you been absent from working during the last 12 months(apart from holidays)
7. Are you now pregnant?
No Yes N/A
 
NOTES
 
Terms of Business

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