EMPLOYMENT APPLICATION FORM Name Date Position Applied For PART A - PERSONAL DETAILS Title Mr Mrs Miss Ms Forename(s) Surname Name Address Postcode Daytime tel. no Evening tel. no Mobile tel no Email National Insurance Number D.O.B NMC pin number (If this does not apply, put N/A) NMC expire date (If this does not apply, put N/A) Do you require a work permit? Yes No If yes, do you have one? Yes No Do you hold a current driving licence? Yes No Do you have an access to a car which you could use for work should this be a requirement of the job? Yes No Name, address and telephone No. to contact in emergencies: PART B – EDUCATION, TRAINING & QUALIFICATIONS Dates School/College/University etc. Qualifications Gained + Add More Membership of Professional Associations Dates Membership Status Professional Body + Add More Training, Seminars or Short Courses attendant relevant to the post (subject, date of attendance, duration) PART C - PAST EMPLOYMENT & EXPERIENCE - Most recent first (please give a complete account since leaving school, including periods of unemployment) Dates Job Title Employer’s Name and Address Reasons for Leaving / Last Pay + Add More PART D - REFERENCES Is your approval required before references are taken up? Yes No Referees (present or most recent employer should be your first referee) 1. Name Address Telephone Email Occupation Position/Relationship 2. Name Address Telephone Email Occupation Position/Relationship PART E – FUTHER INFORMATION NATIONALITY Do you require a work permit to work in the United Kingdom? Yes No COMMUNICATION Can you communicate in sign languages? Yes No Can you communicate in any other languages? Yes No If yes, please state: Have there been any proceedings of medical negligence or professional misconduct against you and have you ever been suspended or dismissed? Yes No If "Yes" please supply details SECURITY Police checks may be carried out on all applicants before they can commence employment. Do you agree that such checks may be made concerning you if required? Yes No PART F - MEDICAL HEALTH DECLARATION Please state the number of days absent from work due to sickness or hospitalisation in the last two years and indicate reasons. Do you consider you have a health problem or a disability relevant to your application? Yes No If yes, please give details: Are you suffering from, receiving treatment for or anticipating any surgical intervention for any medical condition that may affect your ability to carry out normal daily duties? Yes No If answering ‘yes’ to any of the following questions, give full details in the space provided of the dates, duration and outcome of the illness or condition. Any offer of membership may be subject to a satisfactory medical report. HAVE YOU EVER HAD? Chest complaints (TB, asthma, bronchitis)? Yes No IF YES, PLEASE PROVIDE DETAILS Chest pain, heart condition or raised blood Yes No IF YES, PLEASE PROVIDE DETAILS Blackouts, fits, migraine, giddiness? Yes No IF YES, PLEASE PROVIDE DETAILS Depression, mental illness, nervous breakdown Yes No IF YES, PLEASE PROVIDE DETAILS Rheumatism or arthritis? Yes No IF YES, PLEASE PROVIDE DETAILS Back problems? Yes No IF YES, PLEASE PROVIDE DETAILS Typhoid, dysentery? Yes No IF YES, PLEASE PROVIDE DETAILS Digestive or bowel disorders? Yes No IF YES, PLEASE PROVIDE DETAILS Diabetes, thyroid, gland trouble? Yes No IF YES, PLEASE PROVIDE DETAILS Bladder or kidney problems? Yes No IF YES, PLEASE PROVIDE DETAILS Dermatitis of skin trouble? Yes No IF YES, PLEASE PROVIDE DETAILS Varicose Veins? Yes No IF YES, PLEASE PROVIDE DETAILS Any other accident / illness? Yes No IF YES, PLEASE PROVIDE DETAILS Have you any reason to believe you may be infected with any communicable disease? Yes No IF YES, PLEASE PROVIDE DETAILS Any current / recent medical condition which might affect you attendance or performance at work? Yes No IF YES, PLEASE PROVIDE DETAILS Any illness or medical condition that prevented you from attending work or your normal duties and activities for more than one week during the past 12 months? Yes No IF YES, PLEASE PROVIDE DETAILS Any physical disabilities including defect of sight or hearing? Yes No IF YES, PLEASE PROVIDE DETAILS Do you smoke? If so, how many cigarettes per day? Yes No IF YES, PLEASE PROVIDE DETAILS PART G - CRIMINAL CONVICTIONS DECLARATION Have you ever been convicted of a criminal offence which is not spent under the Rehabilitation of Offenders Act 1974? Yes No If yes, please give details: Have you ever been convicted of a criminal offence which is classed as spent under the Rehabilitation of Offenders Act 1974? (Please note this question is asked not to discriminate against those who have previous convictions. When applying for a role which requires a Criminal Records Bureau check, any convictions which appear that you have not disclosed may jeopardise your placement into an assignment). Yes No If yes, please give details: Signature Print Name Date PART H – PERSONAL STATEMENT Date PART I - CONFIDENTIALITY AGREEMENT I confirm that during every assignment and afterwards where: To hold information relating to the client in the strictest confidence, ensure it is kept safely and securely when not in use. I acknowledge that no information is to be removed from the client’s premises without the permission of the Client. To use such information only for the purpose of the work for which it was given. Not to disclose to any third party or copy the information except as is required in the course of my duties.Any breach, either by me or a third party, may result in legal proceedings being bought by the Client against me to recover any losses that have occurred as a result of a breach. Signature Print Name Date PART J - APPLICANTS’ DECLARATION I confirm that I am over 18 years of age. I declare that all the information I have given is true and I understand that any false or misleading information may result in my removal from Famous Recruitment & Management Consultancy staff register. I agree that premiums for professional negligence indemnity insurance and training may be deducted from my fees. I have read and agreed to abide by the conditions of engagement. Signature Print Name Date PART K - EQUAL OPPORTUNITIES IN EMPLOYMENT FAMOUS Recruitment & Management Consultancy is committed to equal opportunities policy, and the purpose of this is to ensure that no job applicant or employee is given less favorable treatment on grounds of sex, marital status, sexual orientation, disability, religion, colour, ethnic or cultural origins or is disadvantaged by conditions of requirements which cannot be shown to be justified. We must ensure that we recognize the differences between people and taking steps to redress imbalances in order to provide equal access to jobs, services and other benefits. FAMOUS Recruitment & Management Consultancy is fully aware and committed to making this policy effective. You are therefore requested to provide the following personal details by placing a tick in the appropriate box for the purpose of monitoring equal opportunities only. Cultural/Ethnic origin White British White Irish White other Black Afro Black Caribbean Black other Indian Pakistani Bangladeshi Chinese Any other Asian background Other (please specify) Religion Christian Muslim Buddhist Jewish Hindu Sikh Other (please specify) None Gender Male Female Sexual Orientation Heterosexual Homosexual Sexual Prefer not to say Marital status Single Married Separated Divorced Widowed Cohabiting Do you consider yourself to have a disability? Yes (registered) Yes (unregistered) No Signature D.O.B Print Name Date YOUR BANK ACCOUNT DETAILS We pay your wages directly into a bank account. Name of bank Account holder name Address Sort Code Account Number I wish to be paid through a Ltd Company and enclose details. (You will be paid as PAYE until you provide all your documentation) OR I am on P.A.Y.E (Please enclose P45 if we are your main employer)
