CONFIDENTIAL
JOB APPLICATION FORM
Title of Post ……………………………………………………………………………………
Based at
……………………………………………………………………………………
PERSONAL DETAILS
Name in Full ……………………………………………. Title (Dr/Mr/Mrs/Ms etc) …….…
Address ……………………………………………………………………………………….
……………………………………………………………. ……………………………………
……………………………………………………………. ……………………………………
(post code) ……………………………………………… ……………………………………
Telephone No ……………………………………………. (Home) ………………………..
……………………………………………………………. (Work) …………………………
How did you hear of the vacancy? ………………………………………………………..
Do you hold a valid current driving licence? ………………………………………………
Do you have any relatives/partners who are currently employed within the
Company?
Yes/No
If yes, please provide the name and home/department
they are based in.
................................................................................................................. ……
(Note: if you are invited to an interview, you will be asked to bring along
documentation in order to prove that you are permitted to work in the United
Kingdom. Please see enclosure for further information.)
REFERENCES
Please give full name and address of two referees, one of whom must be your
present (or, if unemployed, your most recent) employer.
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Name of Employer…………………………… Name of Company .......................
Address ……………………………………….. …………………………………………….
………………………………………………………………….(post code) …………………
Occupation ………………………………Tel No … ………………………………………..
Name of employer…………………………… Name of Company .......................
Address ……………………………………….. …………………………………………….
………………………………………………………………….(post code) …………………
Occupation ………………………………Tel No … ………………………………………..
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May we approach your referees prior to interview?
Yes/No
EDUCATION
NAME OF SCHOOL, COLLEGE ETC.
RESULTS OBTAINED
YEAR
…………………………………………………. …………………………. ……………….
…………………………………………………. …………………………. ……………….
…………………………………………………. …………………………. ……………….
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PROFESSIONAL QUALIFICATIONS
QUALIFICATIONS
TRAINING
DATE GAINED
REG/ROLL NO
ESTABLISHMENT
……………………… ……………………………… ………………… …………………
……………………… ……………………………… ………………… …………………
……………………… ……………………………… ………………… …………………
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N.B. EVIDENCE OF QUALIFICATIONS WILL BE REQUIRED, QUALIFIED NURSES MUST
PRODUCE REGISTRATION/ENROLMENT CERTIFICATES PRIOR TO EMPLOYMENT
UKCC PIN NUMBER ……………………………………… EXP. DATE ……………….
ANY FURTHER COURSES
TITLE OF COURSE
TRAINING ESTABLISHMENT
DATE
……………………………… …………………………………………… …………………
……………………………..
…………………………………………… ………………….
……………………………..
…………………………………………… ………………….
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…………………………………………… ………………….
Any Other Languages Spoken:………………………………………………………………..
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EMPLOYMENT HISTORY
PLEASE GIVE DETAILS OF FULL EMPLOYMENT HISTORY OR ENCLOSE A RECENT CV
(most recent first, ensuring to account for any gaps in employment, please
continue on a separate sheet if necessary). Please include months and years
TITLE OF POST …………………………………… EMPLOYER ………………………
FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….
MAIN RESPONSIBILITIES ……………………………………………………………….
………………………………………………………………………………………………..
………………………………………………………………………………………………..
REASON FOR LEAVING …………………………………………………………………
TITLE OF POST ……………………………………. EMPLOYER ……………………..
FROM ………… TO ………… FULL OR PART-TIME ………….. SALARY …………
MAIN RESPONSIBILITIES ……………………………………………………………….
………………………………………………………………………………………………..
………………………………………………………………………………………………..
REASON FOR LEAVING …………………………………………………………………
TITLE OF POST …………………………………… EMPLOYER ………………………
FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….
MAIN RESPONSIBILITIES ……………………………………………………………….
………………………………………………………………………………………………..
………………………………………………………………………………………………..
REASON FOR LEAVING …………………………………………………………………
TITLE OF POST …………………………………… EMPLOYER ………………………
FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….
MAIN RESPONSIBILITIES ……………………………………………………………….
………………………………………………………………………………………………..
………………………………………………………………………………………………..
REASON FOR LEAVING …………………………………………………………………
TITLE OF POST …………………………………… EMPLOYER ………………………
FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….
MAIN RESPONSIBILITIES ……………………………………………………………….
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REASON FOR LEAVING …………………………………………………………………
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Updated: May 2010
TITLE OF POST …………………………………… EMPLOYER ………………………
FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….
MAIN RESPONSIBILITIES ……………………………………………………………….
………………………………………………………………………………………………..
………………………………………………………………………………………………..
REASON FOR LEAVING …………………………………………………………………
TITLE OF POST …………………………………… EMPLOYER ………………………
FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….
MAIN RESPONSIBILITIES ……………………………………………………………….
………………………………………………………………………………………………..
………………………………………………………………………………………………..
REASON FOR LEAVING …………………………………………………………………
TITLE OF POST …………………………………… EMPLOYER ………………………
FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….
MAIN RESPONSIBILITIES ……………………………………………………………….
………………………………………………………………………………………………..
………………………………………………………………………………………………..
REASON FOR LEAVING …………………………………………………………………
TITLE OF POST …………………………………… EMPLOYER ………………………
FROM ………... TO …………. FULL OR PART-TIME ………….. SALARY ……….
MAIN RESPONSIBILITIES ……………………………………………………………….
………………………………………………………………………………………………..
………………………………………………………………………………………………..
REASON FOR LEAVING …………………………………………………………………
REHABILITATION OF OFFENDERS ACT
Due to the activities of The Regard Partnership Ltd, under the Rehabilitation of
Offenders Act (1974 and 1975), you have a legal obligation to disclose any
criminal convictions you may have, irrespective of whether or not they would be
considered ‘spent’ in other types of industry.
Any such information will be kept in strict confidence and will only be taken into
account in respect of your suitability for the position for which you are applying
and/or for which criminal convictions must be considered. Please note that
successful candidates will be required, for verification purposes, to apply to the
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Updated: May 2010
Disclosure and Barring Service for an enhanced disclosure details of which will be
made available at the appropriate time.
Have you been known by any name other than that shown on the application form
(e.g. maiden name, adoptive or common-law name for example)?
YES/NO
If yes, please provide details:
…………………………………………………………………………………………………..
Should employment be offered, it is on condition that any future convictions or
cautions for a criminal offence must be notified to the management immediately.
Each case would be taken on its merits and suspension or dismissal would not
automatically follow. Failure to disclose, however, may well result in dismissal.
Have you resided at any address other than that quoted on your application for
within the last 5 years?
YES/NO
If yes please give details:
…………………………………………………………………………………………………..
Do you have any convictions or cautions (current or spent since the age of 16)?
YES/NO
Are you currently the subject of any criminal proceedings (for example charged or
summonsed but not yet dealt with) or any police or other official or regulatory
body investigation?
If the answer to either question is YES, please give details below (please continue
on a separate sheet if necessary)
DATE
NATURE OF CONVICTION, CAUTION,
COURT
RESULT
CHARGE, ALLEGATION OR INVESTIGATION
Have you ever been subject to a SOVA/POVA/POCA investigation or police
investigation due to an allegation of abuse against a vulnerable person?
YES/NO
If yes, please give details:
…………………………………………………………………………………………………………
PLEASE GIVE ANY ADDITIONAL INFORMATION WHICH YOU THINK MAY BE
RELEVANT IN SUPPORT OF YOUR APPLICATION. (Continue on a separate sheet if
necessary)
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DECLARATION
I understand that if I am offered employment, the information submitted in my
application will form the basis of my contract of employment with The Regard
Partnership Ltd and that if it is subsequently discovered that I have wilfully or
negligently given false information or withheld any information for whatever
reason, I will be liable for immediate dismissal and may also be prosecuted. All
the information given by me within this application is true to the best of my
knowledge and belief.
Name ………………………………………………………… Date ……………………….
Name ………………………………………………………… Date ……………………….
(To be witnessed by parent, guardian or appropriate adult if applicant is under 17yrs age)
Relationship to applicant: ..............................................................................
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Updated: May 2010
Please email this form to Alison Fraser
[email protected]
FOR OFFICE USE ONLY
Outcome of interview ……………………………………………………………………….
………………………………………………………………………………………………….
…………………………………………………………………………………………………
Documents seen by ………………………………………………………………………….
Passport
Photo ID
Birth Certificate
Others ……………………………………………………………………………………….
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Updated: May 2010