Please complete all sections of this form relevant to the post you are applying for.

Certain roles make it necessary for you to pass a medical examination and a drug screening before an offer of employment can be finalised.
 In completing the form ‘Proof of Identity Verification Data’ (if applicable for role) you hereby agree that Network Rail can disclose the form and the data contained within to a third party for the purpose of performing a Proof of Identity check on our behalf. The third party will not discuss or distribute this data or form to any other party or for any other purposes without first obtaining your prior written permission
.
A
Position applied for: Reference number:
Location of position:
Email Address:
To enable us to monitor the effectiveness of our Recruitment Advertising, please could you indicate where you heard about this position?
Media advertisement* Specific:
Network Rail website Speculative Other (please specify):
*If media advertisement, please state where you saw the advert
B
Title: First name(s): Last name:
Address:
Town:
County
Post Code
Home Telephone Number
Work Telephone Number
Mobile Telephone Number
Nearest Rail Station
Are you legally entitled to take employment in the UK? Yes No
If you answered yes to the above question and this is dependent on a work permit or visa, please list the type of work permit or visa and give the expiry date: (dd/mm/yyyy)
If employment in the UK is dependent on a work permit or visa please attach a photo copy to this application.
Dates of holidays booked in the next 3 months:
Page 1 of 9
Ref: NR/HR/FORM/043
Date Issued: 07/11/0807
Owner: Leadership Development & Resourcing, HR
Version: 1.5

C
Please describe your current or last job.
Job title:
Name of organisation:
Location of work:
Dates: (from/to):
Briefly describe the responsibilities of your job and any major achievements:
What is your current salary and package?
What is your notice period?
What is the reason for leaving:
Previous positions over the last 5 years
Organisation/Company:
Position Held/Nature of Work:
From / To (MM/YYYY)
Previous positions over the last 5 years
Organisation/Company:
Position Held/Nature of Work:
From / To (MM/YYYY)
To
To
Page 2 of 9
Ref: NR/HR/FORM/043
Date Issued: 08/05/07
Owner: Leadership Development & Resourcing, HR
Version: 1.5

Previous positions over the last 5 years
Organisation/Company:
Position Held/Nature of Work:
From / To (MM/YYYY)
Previous positions over the last 5 years
Organisation/Company:
Position Held/Nature of Work:
From / To (MM/YYYY)
For experience gained over 5 years ago please summarise below.
D
Please give examples as to how you match the requirements of the role:
To
To
Page 3 of 9
Ref: NR/HR/FORM/043
Date Issued: 08/05/07
Owner: Leadership Development & Resourcing, HR
Version: 1.5

E
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 (start with highest level first).
Academic qualifications:
Type Subject Year Grade Name & Address of
School or College
Competencies: relevant rail industry, track or other certificates:
Subject or Card Number (e.g.
NCCA card no.)
Subject Date attained
Expiry Date
F
Please answer the following questions regarding health and working patterns.
Awarding
Body/Company
Do you have normal vision? Yes No
Is your colour vision normal? Yes No
Do you wear glasses/contact lenses? Yes No
Is your hearing normal? Yes No
Does your health restrict manual work? Yes No
Working Patterns
Are you prepared to work shifts including nights? Yes No
Are you prepared to work weekends/Bank Holidays as part of your normal working week? Yes No
Are you willing to work outdoors at all times of the year? Yes No
Are you prepared to work overtime if required? Yes No
Do you hold a full and valid UK Driving licence? Yes No
Do you have your own transport for the purpose of getting to work? Yes No
Please include any other details or information that you feel is relevant to your application on a separate sheet.
Page 4 of 9
Ref: NR/HR/FORM/043
Date Issued: 08/05/07
Owner: Leadership Development & Resourcing, HR
Version: 1.5

Page 5 of 9
Ref: NR/HR/FORM/043
Date Issued: 08/05/07
Owner: Leadership Development & Resourcing, HR
Version: 1.5

H
References
References will be checked to ascertain information in respect of your employment history, character and general reputation. In connection with this please provide 2 references, if applicable, relating to your last five years of employment and including your current/last employer. References will always be sought once an offer of employment is made.
Reference 1
Company:
Job Title:
Full Address:
Name:
Contact Phone
Number:
Reference 2
Company:
Job Title:
Full Address:
Name:
Contact Phone
Number:
Page 6 of 9
Ref: NR/HR/FORM/043
Date Issued: 08/05/07
Owner: Leadership Development & Resourcing, HR
Version: 1.5

I
Job applied for: Job reference no:
Location: Today’s date: / /
Please give details of any court martial conviction, outstanding summons or prosecution (except those spent under the
Rehabilitation of Offenders Act 1974). Please visit www.yourrights.org.uk for clarity, should you be unsure as to whether your conviction is spent.
Any false statement will disqualify your application, or in the event of employment, render you liable to dismissal.
Please indicate ‘None’ if none None
Date Nature of Offence Sentence Date Spent
Disability
Under section 20 of the Equality Act 2010, employers have a duty to make reasonable adjustments to the workplace so that a person with a disability is not put to substantial disadvantage in comparison with a person who does not have a disability.
A person is defined as having a disability if they have a physical or mental impairment, and that impairment has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities.
You may be required to undergo an assessment as part of our recruitment process. Would you require any assistance or adjustments to be made?
Yes No
If yes, please note that we will contact you prior to the interview to discuss additional arrangements.
Ethnic origin Please tick one of the boxes below:
White Mixed Black or
Black British
British
White and
Black
Caribbean
White and
Black African
Caribbean
Irish
Other
White backg round
White and
Asian
African
Other Black background
Asian or
Asian British
Indian
Pakistani
Bangladeshi
Chinese or Other ethnic group
Chinese
Any other
Page 7 of 9
Ref: NR/HR/FORM/043
Date Issued: 08/05/07
Owner: Leadership Development & Resourcing, HR
Version: 1.5

Other Mixed background
Other Asian background
If you selected any of the ‘other’ categories, please specify how you would further describe yourself below:
Gender
Please indicate your gender Female Male
Age
Please tell us your age:
Date of birth: / /
Religion
Please indicate your religion
Baia Buddhist Catholic Christian Cof E Hindu
Muslim Jewish Parsi Rastafarian Sikh Other ……………
(please state)
Data Protection Act 1998
In order to comply with the Data Protection Act 1998, Network Rail must obtain consent to hold and use personal information about individuals that could be considered sensitive. The following has been highlighted as sensitive under the Data Protection Act 1998: racial or ethnic origin, political opinions, religious belief, trade union membership, physical or mental health condition, sexual orientation. The Act prohibits the processing of sensitive data except in specified circumstances for example equal opportunities monitoring. It is only in this sensitive area that Network Rail wishes to monitor in order to assess the effectiveness of its equal opportunities policy and to reduce the possibility of discrimination occurring.
Please sign the statement below as your consent for the Network Rail to process sensitive data in this area.
I understand that this information will be used only for the purpose set out in the statement above, and my consent is conditional upon Network Rail complying with the obligation and duties under the Data Protection Act 1998.
Signed:
Name (printed):
Declaration
I agree that any offer of employment with Network Rail will be subject to satisfactory references and medical examination. All successful candidates will have to pass a medical examination and will need to be drug screened before an offer of employment can be finalised.
I declare that all the information given on this application form is correct, and has been completed by myself (in own handwriting when not typed). I understand that my application may be rejected and/or I may be dismissed if it is subsequently found that I have given false information or withheld any relevant details.
Signed:
Date:
When this form is sent by email, the action of sending the e-mail will be regarded as a signed declaration that you have consented to the above declaration.
Page 8 of 9
Ref: NR/HR/FORM/043
Date Issued: 08/05/07
Owner: Leadership Development & Resourcing, HR
Version: 1.5

Thank you for completing this application form.
Please complete this form and attach to your online application.
Page 9 of 9
Ref: NR/HR/FORM/043
Date Issued: 08/05/07
Owner: Leadership Development & Resourcing, HR
Version: 1.5