| Job Application Form
Details
Title of post applied for:
Home:
Before completing this form, please read the accompanying guidance notes.
Please write clearly in black ink and in Block capitals or type.
Personal Details
Surname:
Forenames:
Former
surnames if
different:
Preferred title (Dr, Mr,
Mrs, Ms, Miss etc):
Tel No (home):
Tel No (business):
Tel No (mobile):
Fax No:
Address:
E-Mail address:
Nat. Insurance No:
Nationality:
If you are not a British passport holder or a
European Citizen, or you do not have the
permanent right to remain in the UK, you
will require a work permit.
Do you need a work
permit to be employed
in the UK?
Yes
No
If you already have a work permit,
when does it expire?
(Please note that your current work permit
may not be valid for this post.)
Where did you learn of the post? Please
circle.
Newspaper, Job Centre, Facebook
Word of mouth, other (please state in the
box to the right),
Were you recommended by a friend?
Yes
No
Please advise which of our staff members
referred you to Heathcotes & which of our
services they work for.
EDUCATION AND PROFESSIONAL QUALIFICATIONS
(Original documents as proof of qualification will be required at interview.)
Secondary School
/College/University
Dates
From
To
Examinations
taken
Date
Professional Qualifications currently held: how obtained, grade and date
Other relevant Educational or Training Courses, with dates
Result
Present Post
Title of Post:
Salary/Grade:
Name of Employer:
Business of
Employer:
Date Commenced:
Address:
Date Ended (if
applicable):
Please outline your responsibilities, to whom you are responsible and staff responsible to
you (if applicable):
Reason for leaving or wishing to leave:
Period of notice required to terminate present
employment:
Please notify us of any dates you are available for interview:
Previous Employment
(A full and complete history is required; continue on a separate sheet if necessary).
Dates
Name and Address of
Position held
Final grade/salary
Employers
From
To
Reason for leaving:
Description of duties:
Reason for leaving:
Description of duties:
Reason for leaving:
Description of duties:
Reason for leaving:
Description of duties:
Relevant Skills, abilities, knowledge, experience and your reasons for applying for this job
Other Information
What activities outside work interest you? (State any positions held you consider relevant.)
Do you hold a current driving licence?
Yes
No
Do you own a car?
Yes
No
Disability Discrimination Act 1995
Do you consider yourself to be disabled under the Disability Discrimination Act?
Yes
No
If Yes, are there any adjustments that you think we could make to overcome a
disability in relation to the essential requirements of this job?
Yes
No
If Yes, please provide further details:
If selected for interview, do you require any assistance/adaptations to help you
attend?
Yes
No
If Yes, what assistance/adaptations do you require?
References
Referee 1
Referee 2
Title (Mr, Mrs etc):
Title (Mr, Mrs etc):
Full Name:
Full Name:
Job Title:
Job Title:
Organisation:
Organisation:
Address:
Address:
Tel No:
Tel No:
E-mail address:
E-mail address:
Fax No:
Fax No:
Please state if we may obtain this
reference prior to interview.
Yes
No
Please state if we may obtain this
reference prior to interview.
Yes
No
Rehabilitation of offenders act 1974
By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, the provisions
of Section 4.2 of the rehabilitation of Offenders Act 1974 do not apply to any employment
which is concerned with the provision of health services and which is of such a kind as to
enable the holder to have access to persons in receipt of such services in the course of his
normal duties. Your answer to the following questions should include any “spent”
convictions.
Have you ever been convicted/caution of a criminal offence?
If the answer is ‘yes’ please attach details. Including dates.
Yes
No
Declaration
I declare that the information given in this application form is true and complete. I
understand that if I have given any misleading information on this form or made any
omissions, this will be sufficient grounds for terminating my employment.
Signature:
Name:
Date:
The information provided by you on this form as an applicant will be stored either on paper
records or a computer system in accordance with the Data Protection Act 1998 and will be
processed solely in connection with recruitment.
| 3.0 DBS Consent Form
Are you signed up to the DBS Update Service? Yes OR No
NEW EMPLOYEES ONLY
YesI …………………………... declare that I am already signed up the DBS Update Service, I also
understand that in the event of signing the below, I am consenting that my employer,
Heathcotes Group, can process on-going status checks as and when needed through the
update service.
Signed:
Date:
NoI …………………………... declare that I agree to sign up to the DBS Update Service for the fee of
£13.00, the cost of which will be met by myself. This money will be reimbursed to me by the
company after successful completion of my 6 month probationary period.
I also understand that in the event of signing up the DBS Update service, I am consenting that
my employer, Heathcotes Group, can process on-going status checks as and when needed
through the update service.
Signed:
Date:
EXISTING EMPLOYEES ONLY
I …………………………... declare that I agree to sign up to the DBS Update Service for the fee of
£13.00, the cost of which will be met by myself. This money will be reimbursed to me by the
company on completion of an expenses claim form.
I also understand that in the event of signing up the DBS Update service, I am consenting that
my employer, Heathcotes Group, can process on-going status checks as and when needed
through the update service.
Signed:
Date:
PLEASE RETURN TO: INSERT HOMES DETAILS HERE