Application For Employment
Private and Confidential
Ref. No.
Position applied for
Name (Title)
Forename(s)
Surname
Address
Post Code
Email Address
N.I. Number
Telephone Number (Landline)
Telephone Number (Work)
Mobile
Upload Picture
Current Driving Licence?
Yes
No
Groups
Expiry Date
Details of Endorsements
Are there any restrictions on you taking up employment in the UK?
Yes
No
(If Yes, please provide details)
Education
Schools/Colleges/University
Qualifications Gained
Other Training
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Employment History: (Please complete in full and use a separate sheet if necessary)
From
To
Name and Address
Job Title
Rate of Pay
Duties
Reason for leaving
From
To
Name and Address
Job Title
Rate of Pay
Duties
Reason for leaving
From
To
Name and Address
Job Title
Rate of Pay
Duties
Reason for leaving
From
To
Name and Address
Job Title
Rate of Pay
Duties
Reason for leaving
From
To
Name and Address
Job Title
Rate of Pay
Duties
Reason for leaving
Current membership of professional bodies
Please note any professional bodies you are a member of or are registered with
Professional Registration Number (Where applicable)
Registration/PIN Number (Nursing)
GMC Certificate Number (Doctors)
Other employment
Please note here any other employment you would continue with if you were to be successful in obtaining this position
Leisure
Please note here your leisure interests, sports and hobbies, other pastimes etc.
References: Please note here the names and addresses of two persons from whom we may obtain both character and work experience references.
Name 1
Position
Address
Post Code
Telephone
May we approach the above prior to interview?
Yes
No
Name 2
Position
Address
Post Code
Telephone
May we approach the above prior to interview?
Yes
No
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General Comments
Please detail here your reasons for this application, your main achievements to date and the strengths you would bring to this post. Specifically, please detail how your knowledge, skills and experiences meet the requirements of this role (as summarised in the person specification).
Cautions, rehabilitation and criminal records
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 Exceptions order 1975 as amended by the Exceptions (Amendment) Order 1986, which means that convictions that are spent under the terms of the Rehabilitation of Offenders Act 1974 must be disclosed, and will be taken into account in deciding whether to make an appointment. Any information will be completely confidential and will be considered only in relation to this application.
In addition you are required to submit to a Disclosure and Barring check/provide a PVG Scheme Record or Scheme record update. Any disclosure made by the Disclosure and Barring Service/Disclosure Scotland will remain strictly confidential.
Have you ever been convicted in a Court of Law and/or cautioned in respect of any offence? YES/NO (delete as required). If YES, please give details.
Special requirements (care sector)
Because this position involves the care of children and /or vulnerable adults employment is dependent on the following:
1). Your written consent to obtaining a Disclosure and Barring certificate from the Disclosure and Barring Service/Disclosure Scotland or an approved umbrella body or provision of a PVG Scheme Record/Scheme record Update.
2). Such disclosure being acceptable to us.
3). Proof of identity - birth or marriage certificate (where appropriate) and passport (if available).
4). Two satisfactory written references.
5). That you will supply a photograph of yourself for retention in our records.
6). Evidence of physical or mental suitability for your work.
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Declaration (Please read this carefully before signing this application)
1. I confirm that the above information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.
2. Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my employee file during employment and for up to six years therafter and understand that doctor. I agree that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my employee file during employment and for up to six years therafter and understand that information will be processed in accordance with the Data Protection Act.
3). I agree that my previous employers may be approached for references. I also agree that should I be successfl in this application, I will apply to the Disclousure and Barring Service/Disclosure Scotland for a Disclosure and Barring certificate/PVG Scheme Record or Scheme Record Update. I understand that should I fail to do so, or should the disclosure or reference not be satisfactory, any offer of employment may be withdrawn or my employment terminated.
All organisations using the Disclosure and Barring Service and/or Disclosure Scotland to help assess the suitability of applicants for positions of trust and who are recipients of disclosure information must comply fully with the relevant Code of Practice. Amongst other things this obliges them to have a written policy on the recruitment of ex-offenders. This must be given to all applicants for posts where a disclosure will be requested. the code also requires such organisations to have a written policy on the correct handling and safekeeping of Disclosure information. To assist organisations in meeting this requirement a sample policy statement on the recruitment of ex-offenders will be included with any stationery requests for Form AP2(H).
Policy statement on the recruitment of ex-offenders
1. As an organisation using the Disclosure and Barring Service/Disclosure Scotland to assist in assessing applicants suitability for positions of trust, the company complies fully with the relevant Code of Practice (a copy of which is available on request) and undertakes to treat all applicants for all posts fairly. the company will not discriminate unfairly against any subject of a disclosure on the basis of a conviction or other information revealed.
2. We actively promote equality of opportunity for all and we select all candidates for interview on the basis of their talent, skills, qualifications and experience. We welcome applications from a wide range of candidates, including those with criminal records.
3. A disclosure is only requested where it is legally required or after a thorough risk assessment has indicated that one is both proportionate and relevant to the position concerned. Where a disclosure will be required from a successful candidate, all applicants will be made aware of this at all stages of the recruitment process.
4. Where disclosure is to form part of the recruitment process, we encourage all applicants called for interview to provide details of their criminal record at an early stage in the application process.
5. Unless the nature of the position allows the company to ask questions about a candidate's entire criminal record we only ask about "unspent" convictions as defined in the Rehabilitation of Offenders legisiation.
6. We ensure that all those in the company who are involved in the recruitment process have been suitably trained to identify and assess the relevance and circumstances of offences. We also ensure that they have received appropriate guidance and training in the relevant legisiation relating to the employment of ex-offenders.
7. At interview, or in a separate discussion, we ensure that a open and measured discussion takes place on the subect of any offences or other matter that may be relevant to the position. Failure to reveal information that is relevant to the position sought could lead to withdrawal of an offer or termination of employment.
8. We undertake to discuss any matter revealed in a disclosure with the person seeking the position before withdrawing a conditional offer or terminating employment.
9. Having a criminal record will not necessarily bar an applicant from working for us. This will depend on the nature of the position and the circumstances and background of the offences.
Equal Opportunity Monitoring
Private and confidential
We are an equal opportunity employer. The aim of our policy is to ensure that no job applicant or employee receives less favourable treatment because of age, disability, gender reassignment, marriage and civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation.
Our recruitment selection criteria and procedures (including the areas or media sources which are used in the recruitment process) are frequently reviewed to ensure that individuals are selected, promoted and treated on the basis of their relevant merits and abilities and that no applicant or employee is disadvantaged by provisions, criteria or practices which cannot be shown to be justified.
To ensure that this policy is fully and fairly implemented and monitored, and for no other reason, would you please provide the following information:-
I would describe my ethmic group and sex as:- (please tick one box for your ethnic group and one box for your sex).
A) White
English
Scottish
Welsh
Irish
Any other White background, please specify
B) Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background, please specify
C) Asian, Asian British, Asian English, Asian Scottish or Asian Welsh
India
Pakistani
Bangladeshi
Any other Asian background, please specify
D) Black, Black British, Black English, Black Scottish or Black Welsh
Caribbean
African
Any other Black background, please specify
E) Chinese, Chinese British, Chinese English, Chinese Scottish or Chinese Welsh or other Ethnic Group
Chinese
F) Any other background
Please specify
G) Sex
Male
Female
Other
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Health Questionnaire
Private and confidential
(Subject to satisfactory health checks)
If the answer is yes to any of the questions on this form, please give full details in the space provided of the dates, duration and outcome of the illness or condition. If we have any concerns about your fitness for work, employment will be subject to satisfactory medical reports.
Have you ever had:
Tuberculosis, asthma, bronchitis or chest problems?
Delete as applicable
Yes
No
Additional Information to "YES" response
Chest pain, heart condition or raised blood pressure?
Delete as applicable
Yes
No
Additional Information to "YES" response
Blackouts, fits or attacks of giddiness?
Delete as applicable
Yes
No
Additional Information to "YES" response
Depression, mental illness or nervous breakdown?
Delete as applicable
Yes
No
Additional Information to "YES" response
Rheumatism or arthritis?
Delete as applicable
Yes
No
Additional Information to "YES" response
Back trouble?
Delete as applicable
Yes
No
Additional Information to "YES" response
Typhoid, paratyphoid or other infectious disease?
Delete as applicable
Yes
No
Additional Information to "YES" response
Digestive or bowel disease?
Delete as applicable
Yes
No
Additional Information to "YES" response
Diabetes, thyroid or other gland trouble?
Delete as applicable
Yes
No
Additional Information to "YES" response
Bladder or kidney trouble?
Delete as applicable
Yes
No
Additional Information to "YES" response
Dermatitis or skin trouble?
Delete as applicable
Yes
No
Additional Information to "YES" response
Varicose veins?
Delete as applicable
Yes
No
Additional Information to "YES" response
Vision or Hearing problems?
Delete as applicable
Yes
No
Additional Information to "YES" response
Any other accident, operation or illness?
Delete as applicable
Yes
No
Additional Information to "YES" response
Have you any reason to believe you may be infected with any communicable disease?
Delete as applicable
Yes
No
Additional Information to "YES" response
Any other current or recent medical condition or treatment which might affect your attendance or performance at work?
Delete as applicable
Yes
No
Additional Information to "YES" response
Do you intend to work night duties on a regular basis?
Delete as applicable
Yes
No
Additional Information to "YES" response
Any illness or medical condition that prevented you from attending work on your normal duties or activities for more than one week during the past year?
Delete as applicable
Yes
No
Additional Information to "YES" response
Any physical or mental impairment which has a substantial and long term effect on your ability to carry out day to day activities> If yes, please specify any special adjustments required in relation to work.
Delete as applicable
Yes
No
Additional Information to "YES" response
Do you smoke?
Delete as applicable
Yes
No
Additional Information to "YES" response
How many units of alcohol do you drink per week?
(1 unit = 1/2 pint beer = 1 glass wine = 1 single whisky
Name
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Date
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