CONFIDENTIAL
APPLICATION FOR EMPLOYMENT
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Please answer all questions fully using black or blue ink only
Do not enter ‘refer to CV’ in any categories.
Use additional sheets if necessary, but firmly attach them to this form.
Please ensure that you sign the declaration on the back page
A
VACANCY DETAILS
Position Applied
For
B
Reference
PERSONAL DETAILS
Title (Mr, Mrs, Miss, Ms, etc):
Surname:
Forename(s):
National Insurance Number:
Current Home address (all correspondence relating to your application will be sent to this address):
Postcode:
Telephone (home):
Telephone (work):
Mobile:
E-mail:
Do you have a full driving licence?
YES/NO
Do you have any current endorsements?
YES/NO
Do you have use of a car?
YES/NO
Office use only
Short-listed for interview:
Yes
Right to Work Documents Checked:
Yes
Driving Licence required for role:
Yes
Driving Licence checked:
Yes
Qualification Certificates Checked:
Yes
Offer made/ References obtained:
Yes
Health Shield Friendly Society Limited
Vacancy Application Form R Bound 2010
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No
No
No
No
No
No
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Hold
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CONFIDENTIAL
APPLICATION FOR EMPLOYMENT
PERSONAL DETAILS CONTINUED
Have you ever been subject to Disciplinary Proceedings?
If yes, please indicate the outcome below:
Yes/No
Convictions
Have you ever been convicted of a criminal offence? If so please give details of any unspent convictions.
Spent convictions do not have to be declared as the job is not one covered by the Rehabilitation of Offenders
Act 1974 (Exceptions) Order 1975.
Any false statement will disqualify your application, or in the event of employment, render you liable to
dismissal. Please write none if none.
Bankruptcy
Have you ever been subject to bankruptcy proceedings or court judgements for debt, or are there any
proceedings pending?
YES/NO
If yes, please give details:
Health Shield Friendly Society Limited
Vacancy Application Form R Bound 2010
Page 2 of 7
CONFIDENTIAL APPLICATION FOR EMPLOYMENT
C
EDUCATION, TRAINING AND EXPERIENCE
In this section please list those qualifications you feel are most relevant to your application. Please note that
we will want to see copies of your certificates should your application be successful.
Secondary Education
Further/higher Education
Duration
attended
Qualifications/Grade
Duration
attended
Qualifications(with
date)/grade
Other relevant training, professional qualifications or work related skills (for example
languages, shorthand, etc State date attained.)
Are you undertaking any course of study at present? (if so, please give details)
Do you have membership of any professional bodies? (if so, please give details including
offices held)
It is the Company’s policy to verify the qualifications of all successful job applicants and you may be
asked at a later stage in the recruitment process for your consent to checks being carried out
Health Shield Friendly Society Limited
Vacancy Application Form R Bound 2010
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CONFIDENTIAL APPLICATION FOR EMPLOYMENT
D
EMPLOYMENT
& UNEMPLOYMENT HISTORY
Beginning with the most recent, all periods since leaving full-time education should be accounted for e.g. unemployment, voluntary work, self-employment, raising a
family or any part-time work undertaken whilst in education (continue on a separate sheet if necessary).
Job Title
Employer’s Name,
Address &
Telephone Number
Health Shield Friendly Society Limited
Vacancy Application Form R Bound 2010
Salary
Start & end
date of
employment
Responsibilities, accountabilities and achievements
(include roles and projects in addition to your day-today activities)
Page 4 of 7
Reason for
Leaving
CONFIDENTIAL APPLICATION FOR EMPLOYMENT
E
ADDITIONAL EVIDENCE TO SUPPORT YOUR APPLICATION
Please give any details (including hobbies & interests) you feel are relevant in support of your application,
including why you are interested in this post. Use additional sheets if necessary.
Health Shield Friendly Society Limited
Vacancy Application Form R Bound 2010
Page 5 of 7
CONFIDENTIAL APPLICATION FOR EMPLOYMENT
F
FURTHER INFORMATION
Where did you see the advertisement for the post?
What is the notice period required in your present post?
Are you a British subject or a national of any EEA country?
Do you have the right to work in the UK?
YES/NO
YES/NO
Right to work documents you can submit:
UK Passport
EEA Passport/ID Card
UK Birth Certificate/Adoption Certificate
Entry Clearance/Visa Stamp/Residency Permit
Home Office/Border Immigration Authority Letter
Certificate of Application
Right of Residence as Family Member (Stamp)
If Other please specify:
References
Please give details of two referees, stating how long you have known them. (One should be your current
or most recent employer.) References for short listed candidates will be taken up before interview unless
you request otherwise.
1. Name:
2. Name:
Address:
Address:
Telephone Number:
Telephone Number:
Occupation:
Occupation:
In what capacity known & length of time known:
In what capacity known & length of time known:
May references be taken up before interview?
May references be taken up before interview?
YES/NO
YES/NO
Health Shield Friendly Society Limited
Vacancy Application Form R Bound 2010
Page 6 of 7
CONFIDENTIAL APPLICATION FOR EMPLOYMENT
Data protection
Health Shield will use the information you have provided on this application form, together with any other
information we may obtain about you, e.g. from your referees, to assess your suitability for employment
with us, for administration and management purposes and for statistical analysis.
If your application is unsuccessful, we will keep your information for a reasonable period in accordance
with legal requirements and for administration purposes.
If you provide us with any sensitive information about yourself (e.g. your health, criminal convictions) you
consent to our processing that information for the purposes provided above.
Information from this application may be processed for the purposes registered by the Employer under the
Data Protection Act 1998. Individuals have, on written request [on payment of a fee] the right of access to
personal data held about them.
Declaration
I declare that the information given in this application and in any additional information I enclose is true,
with nothing having been omitted that would affect this application. I hereby give my consent to Health
Shield processing the data supplied in accordance with the purposes stated above.
Note: Any false, incomplete or misleading statements may lead to dismissal.
Signed:
Please return to:
Date:
Thank you for completing this form.
HR & Training Manager
Health Shield Friendly Society Limited
Electra Way
Crewe Business Park
Crewe
Cheshire
CW1 6HS
Health Shield Friendly Society Limited
Vacancy Application Form R Bound 2010
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