LISSUE INDUSTRIAL ESTATE  MOIRA ROAD
LISBURN  CO ANTRIM  N. IRELAND  BT28 2RF
TEL: (028) 9262 1515  FAX: (028) 9262 0869
Position applied for:
Surname:
Title:
Address:
Mr / Mrs / Ms
Forenames:
Address: Address:
Telephone Nº: Telephone Nº:
N.B. References will not be taken up without obtaining applicants permission.
Ref Nº:
Telephone No:
Postcode:
Mobile No:
Marital Status: Married / Single / Other
Next of Kin – Name:
Address:
Relationship:
Telephone Nº:
No of Children:
Do you have a current driving license? Yes / No Are you a car owner? Yes / No
Have you ever been convicted of any offence?
PERSONAL REFERENCES
Please give details to two people (not relatives) we could approach for references:
Name:
Occupation:
Name:
Occupation:
P18 5-3
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School / College / University Subject Taken Specify Grades
Degrees, Professional Qualifications, Membership of Professional Organisations & Institute
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Name & Address of Employer
From / To
Position held, Brief description of duties
Reason for leaving
Name & Address of Employer
From / To
Position held, Brief description of duties
Reason for leaving
Name & Address of Employer
From / To
Position held, Brief description of duties
Reason for leaving
Name & Address of Employer
From / To
Position held, Brief description of duties
Reason for leaving
When would you be available if offered employment?
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Interests and leisure activities:
Please state why you consider you are suitable for this vacancy:
I declare that the information give on this form is correct. I understand that any false information may lead to an offer of employment being withdrawn.
Date: Signed:
Ref Nº:
Monitoring Nº:
Under the Fair Employment Act (NI) every company with more than 25 employees is required to submit on an annual basis a monitor of the religious affiliation of their workforce. In order that we can satisfy this requirement
I am asking you to indicate the appropriate answer.
Please indicate the gender and community to which you belong by ticking the appropriate boxes below.
I am a male
I am a female
I am a member of the protestant community
I am a member of the Roman Catholic community
I am a member of neither the Protestant nor the Roman Catholic community
When completed please return this application form with this portion still attached to the Monitoring Officer.
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PRIVATE AND CONFIDENTIAL
WARMFLOW ENGINEERING CO LTD
Company Name
Division / Location
PLEASE PRINT DETAILS
Surname
Division
Forenames Title
Job Title
Present Address
GP’s Name and Address
Home Telephone Number
GP’s Telephone Number
1. Are you registered under the Disabled Persons Act?
If yes please give full details of dates, and level of treatment
2. Please state whether you have ever suffered from or had any symptom of the following complaints:
Bronchitis, asthma, persistent cough, TB, pleurisy or infection of the lungs or throat?
Rheumatism, arthritis, gout or rheumatic fever?
Blood pressure, palpitations, shortness of breath, chest pain or any infection of the heart?
Fits, fainting, black-outs or any disease of the nervous system?
Chronic or persistent indigestion, gastric or duodenal ulcer or other infection of the abdominal organs?
Any infection of the liver, prostate, kidneys, urinary systems or reproductive system?
Infection of the ears and eyes or any defect of hearing, sight, nose or throat?
Hepatitis A, B or C or any other recognised blood disorder?
Any disease which may have arisen in the tropics?
Mental breakdown, anxiety, depression, tension or stress, including Post Trauma
Stress Disorder?
Diabetes, thyroid disease or any other glandular disorder?
Any accident, physical defect, disc or problem deemed as "Back Trouble" or hernia?
Upper Limb Disorder, Tenosynovitis or Repetitive Strain Syndrome or Injury (RSI),
Hand/Arm Vibration Syndrome or Vibration White Finger?
Have you ever had treatment of any illness or injury which is consequential upon
(i)
(ii)
(iii)
Human Immunodeficiency Virus (HIV) and/or
Acquired Immunodeficiency Syndrome (AIDS) and/or any mutant derivative or variation thereof however caused?
Dermatitis, eczema or other similar allergic rashes?
Alcoholism or Drugs Dependency? (other than in the form of Medically prescribed treatments - Full details to be given under Question 9)
Any illness or injury arising through contamination by any form or radio-activity?
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3. Do you suffer from any physical or mental or psychological defect or partial disability (e.g. poor eyesight/colour blindness, hearing impairment, balance defect, sense of smell etc.) or any other condition, not already disclosed above, which may affect your skills or safe working ability and/or the welfare or safety of your work colleagues or other third parties? YES / NO
If yes, please give full details of dates, level of treatment and any resulting restrictions.
4. Have you ever submitted to any of the following:
Surgical or emergency operation
9.
10.
11.
12.
13.
14.
X-ray examination
Electrocardiogram (ECG) test
Other medical investigations
5. Are you allergic to any drugs, foodstuffs or other specific substances?
If yes please give full details
Tobacco
6. Average Consumption:
Alcohol
Day / Week
Day / Week
Please also provide the following information:
7. The average number of days PER ANNUM you have been absent from work, school or university for health reasons during the last five years.
8. Please complete the section below for periods of sickness absence of five days or more during the past five years
Reason for absence Month and year
Nº working days absent
Are you currently receiving any medical treatment or taking any medication or on any special diet? Please give brief details.
Have you attended or consulted your own doctor, a specialist or consultant, or been admitted to any hospital or clinic either as an inpatient, out-patient or casualty department patient at any time in the last 6 months. If the answer is yes, brief details please.
Do you expect to be absent for medical reasons during the next 12 months? If the answer is "yes", brief details please.
Have you ever been refused employment because of your health? (If yes please give full details)
Is this you first employment with this company? If not, which month and year did you leave the company? At which office/location did you work?
Have you ever lodged a formal claim against any previous (or current) employers for a work related accident or illness. Please supply full details.
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Please read carefully before signing.
1. I declare that having read and checked the above answers, they are, to the best of my ability true and correct in every respect.
2. I give the Company permission to contact my doctor, consultant or specialist for further and better particulars of my medical records, should the company so decide. I understand that the report will be treated in confidence by the medical department but that advice based upon it may be given management.
3. I am prepared to undergo a medical examination at the Company's request if this is required and that details of any examination may be released to my own doctor if this is considered necessary by the company medical adviser.
4. I understand and accept that the Company may, at its discretion, incorporate this questionnaire and my answers as an integral part of any subsequent / Contract of Employment which I may be offered.
5. I understand and accept that if any of the information given by me in this questionnaire is incorrect or untrue, that the
Company reserves the right to immediately terminate my employment with them .
Signed: Date:
1. OBJECTIVES
To ensure that the talents and resources of employees are utilised to the full and that no job applicant or employee receives less favourable treatment on the grounds of his/her community background or is disadvantaged by conditions or requirements which cannot be shown to be relevant to performance.
2. POLICY
To this end the company will:-
2.1 fulfil its social responsibilities towards its employees and the community in which it operates;
2.2 comply with the legal obligations imposed by the Fair Employment (Northern Ireland) Acts;
2.3 review at least once every 3 years its employment composition and practices to determine whether members of each community are enjoying, and are likely to continue to enjoy, fair participation in employment;
2.4 seek to give all employees equal opportunity and encouragement to progress within the organisation by implementing an affirmative action programme, where appropriate;
2.5 distribute and publicise this policy statement throughout the company and elsewhere as is from time to time appropriate;
2.6 provide facilities for any employee who believes that inequitable treatment has been applied to him/her within the scope of this policy to raise the matter through the appropriate grievance procedure;
3. RESPONSIBILITIES
3.1 All employees have a responsibility to accept their personal involvement in the practical application of this policy but specific responsibility falls upon managers, supervisors and staff professionally involved in recruitment; employee administration and training.
3.2 All employees are required to comply with the company's policy of not permitting the display of flags, emblems, posters, graffiti, or the circulation of materials, or the deliberate articulation of slogans or songs, which are likely to give offence to, or cause apprehension among, existing or potential employees.
Breaches of this policy and practice will be regarded as misconduct and could lead to disciplinary proceedings.
Date: 10 th May 1999 Signed:
MR J K COUSINS
MANAGING DIRECTOR
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