Step 1: Personal Details

    Full Name:*
    Address:
    Telephone: (Please include full STD code)  
    Home Telephone:*
    Work Telephone
    Mobile:
    Email Address* (Where Possible)
       
    Do you hold a current driving license? Yes No

    Are there any restrictions regarding your employment?                      
    e.g. do you require a Work Permit?

    		 Yes No
    (If you answer Yes, please supply details)

    How much notice do you need to give to your current employer?
    Is there anything concerning your medical history or state of health that is relevant to your application?                  Yes No

    If you answer Yes, please provide information here and if necessary on a separate sheet of paper in order to support your application form.

Step 2: Employment History


Please start with your most recent employment. Briefly describe the main duties and responsibilities of your post, which should support your application. If you wish to expand on specific areas of responsibility, please do on a separate sheet of paper, stating ‘Employment Record Continued’. Provide full postal address including the post code. Provide a full employment history of at least 10 years.

Current / most recent employer:

Address / contact number:
Job Title: Position Held From: Position Held To:

Brief description of main responsibilities duties performed:

Reason for leaving / changing:

Employers name:

Address / contact number:
Job Title: Position Held From: Position Held To:

Brief description of main responsibilities duties performed:

Reason for leaving / changing:

Employers name:

Address / contact number:
Job Title: Position Held From: Position Held To:

Brief description of main responsibilities duties performed:

Reason for leaving / changing:

Employers name:

Address / contact number:
Job Title: Position Held From: Position Held To:

Brief description of main responsibilities duties performed:

Reason for leaving / changing:

Employers name:

Address / contact number:
Job Title: Position Held From: Position Held To:

Brief description of main responsibilities duties performed:

Reason for leaving / changing:

Step 3: Education and Qualifications


Please tell us about your education and any qualifications which you feel are relevant to the post. (eg GCSE / ‘A’ Level / NVQ / Degree).

Name of school / college / university:

Subject studied:

 Qualifications / Level: Date gained:

Member of Professional Bodies:

Membership / Registration Number:

 Registration / Renewal Date:

Training:

Please list any training you have received or courses attended. These may not necessarily lead to a qualification, but may be relevant for the applied post:

Training Course Date
   

Step 4: References


Criminal Convictions

Do you have any criminal convictions? Include, caution and reprimand? (Include any which you may otherwise consider to be ‘spent’.)*
Yes No

If YES please provide details:

‘A criminal record will not necessarily prevent employment. Any information received will be considered only in relation to the application made. Information will be maintained as confidential. Posts are also 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. You are therefore NOT entitled to withhold information about convictions which for other purposes are ‘spent’ under the Provisions of the Act. In the event of employment, and by own omission failure to disclose such convictions could result in dismissal’.

References

Name:
Position:
Organisation:
Address:
Telephone:
Name:
Position:
Organisation:
Address:
Telephone:

Step 5: Declaration



In accordance with Data Protection Act 1998, the information provided on this form will be used in recruitment and the selection process and may be disclosed to all those who need to see it. It will also form the basis of the ‘Confidential Personnel File’ for successful applicants. In the case of unsuccessful candidates the Application Form will be destroyed after six months.

By signing and returning the application form you are declaring that to the best of your knowledge all the information given by yourself is correct. You also do not object to the information collected on this form being transferred onto computer data base for the purpose of anonymous statistical reporting, in accordance with statutory requirements, and assisting ‘FREEDOM’ Supported Living in equal opportunities monitoring in respect of job applications. I agree that ‘FREEDOM’ Supported Living have the right to validate any information provided.

I understand that any false information / statements could result in my dismissal if at a later stage this information is found to be false.*

Full Name:*
Digital Signature (Repeat your name here as proof of acceptance):*
Date:*