12-month Placement Application Form
Personal Details
Title
Forenames
Surname
What name do you prefer to be
known by?
Contact numbers
Home:
Mobile:
Email address
Home address
Postcode
If your term time address is different to the above, please provide the details below.
Term address
Postcode
Dates at term address
Which placement are you applying for?
Please refer to the list of current placements at http://www.co-operative.coop/Graduates/Workplacements/Our-opportunities/ .
Role title
Reference number
Source of Application
Please indicate how you heard about the placement
Careers Service (please specify)
Careers Service Guide (please specify)
On campus skills session (please specify)
Careers Fair (please specify)
Recruitment Fair (please specify)
I’m a current employee
Referral from Co-operative Group employee
Referral from a friend
Posters
Altogether Different Website
The Co-operative Group website
Times Top 100
Prospects Directory
Prospects.ac.uk
Google Search
Other
Your Academic Experience
Please complete a line for each set of qualifications including:
 GCSEs (or equivalent)
 A levels (or equivalent)
Secondary Education
Qualification
Subjects
e.g. GCSE
e.g. Drama, English, Maths, French
Grades
A,A,B,C
UCAS points obtained to date: ______________________
University Education
Please complete a line for each qualification including:
 your degree
 a further line for any post-graduate qualifications
Place of study
Qualification
Subject
Degree
Classification
e.g. Manchester BSc Hons
English
2:1
Expected/
Obtained
Obtained
University Experience
Please indicate any positions of responsibility you have held at university.
Positions of responsibility
Elected
Please detail tasks and responsibilities.
Course Representative
Society Chairperson
Student Union Post
Society/Team Member
Other (please specify)
What do you consider to be your major achievements whilst at university and why?
These can be academic or non-academic
Your Work Experience
Paid work
Please give details of any work experience that you have gained.
This can include part-time work, vacation work or industrial placements.
Organisation
Please detail the position held and key responsibilities
Voluntary Work
Have you ever undertaken any significant amount of voluntary work such as a VSO, Gap Year
Project, Youth Leader etc?
Yes
No
If yes, please give details indicating your role, what experience you have gained and your
responsibilities.
Organisation
Position held and key responsibilities
Your Skills and Interests
We are asking these questions to understand a little more about your skills and motivations.
To answer them, you can draw on examples from your academic, social and working life.
Why are you interested in the placement role you are applying for?
Why are you interested in working for The Co-operative Group?
How does your degree course make you a good candidate for the role?
What other experience and interests do you have that will make you a good candidate for
the role?
What skills and experience do you want to gain from the role?
What are your long term career aims and how this placement will help with achieving
those aims?
Please describe a major challenge that you have faced and how you responded
Any other information
Is there any additional information about yourself which you think would be of interest e.g.
scholarships, prizes, positions of responsibility, hobbies, interests, extra qualifications etc? If
so, please detail it below
Connections with The Co-operative Group
Are you currently working for The Co-operative Group?
Yes
No
If yes, please give details
Have you previously worked for The Co-operative Group?
Yes
No
Diversity Monitoring
Date of Birth:
Sex:
Male
Female
Please select the option that most closely matches your ethnic group;
Asian or Asian British – Indian
Asian or Asian British – Pakistani
Asian or Asian British – Bangladeshi
Asian or Asian British – Other
Black or Black British – Caribbean
Black or Black British – African
Black or Black British – Other
Mixed – White and Black Caribbean
Mixed – White and Black African
Mixed – Other
White – British
White – Irish
White – Other
Chinese
Other
Prefer not to say
The Disability Discrimination Act defines a disabled person as:
 Having a mental or physical impairment
 Having an adverse effect on an individuals ability to carry out normal day-to-day activities,
such as mobility, manual dexterity, physical coordination, continence, ability to lift, carry or
move everyday objects, speech, hearing or eyesight, memory, ability to concentrate, learn
or understand, understanding physical danger
 Where the adverse effect is substantial and long term (i.e. more than 12 months)
If you feel that the above definition applies to your own circumstances, please tick the
appropriate box below and give further details in the space provided. This will enable the
Society to make any special arrangements that may be necessary for interviews.
Do you have a disability?
Yes
No
Prefer not to say
Please select the option that most closely matches your Disability status;
Hearing Impairment
Visual Impairment
Mobility
Co-ordination/Dexterity
Learning Difficulties
Mental Health
Other
None
Prefer not to say
Please indicate any individual access facilities or special requirements that you would
require at work in order to attend an interview:
Ramps
Car Parking
Equipment
Communicator
Others (please state)
Please indicate your religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other
None
Prefer not to say
Do you have any criminal convictions?
(Do not include any criminal convictions which are ‘spent’ under the Rehabilitation of
Offenders Act 1974)
Yes
No
If yes then please provide any information to be considered as part of your application.
Please select the option that most closely describes your sexual orientation;
Bisexual
Gay Man
Lesbian Woman
Heterosexual/Straight
Other
Prefer not to say
Declaration and Submission
I declare that the information given in support of my application is, to the best of my knowledge,
true and complete.
I understand that any false or misleading statement may be sufficient cause for rejection or, if
employed, dismissal.
Acceptance of Declaration
Yes
No
N.B. Please save your application form as a “Word 1997 – ’00” document (.doc) to ensure all systems can
access it, and return it to us by email at undergraduates@co-operative.coop.