|Application Form | |THE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED IN CONFIDENCE. | |Please note that the closing date for this job vacancy is Monday 30th April 2013. apply for this post please accompany this | |application form with your curriculum vitae and a cover letter. | |We will require you to be available on 1st May 2013 for interviews. | |Section 1 Personal details | Title: | |Last Name: | | |First Names: | | |Address: | | | | | | | | Postcode: | | | | |Home Telephone Number: | | |Mobile Telephone Number: | | |E-mail address: | | |Are you eligible to work in the UK? Yes | |No | | |Do you hold a full UK driving licence? |Yes | |No | | | | |If yes, Do you have any points or convictions etc? : | | | | | | |Section 2 Rehabilitation of Offenders Act | |Have you ever been convicted of a criminal offence? |Yes | |No | | |Have you any prosecutions pending? |Yes | |No | | If yes, please give details / dates of offence(s) and sentence: | | | |Section 3 Health | |Number of days absent in the last 2 years: | | |Please state number of times in the last 2 years: | | | |Are you registered disabled? |YES No | |If yes please provide your disability number and details: | | | | | |Section 4 Education | Date From |Date To |Name of School |Examinations taken and Qualifications Gained (Specify Grades) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Section 5 Employment Record |
Please list chronologically, starting with current or last employer |Name and Address of Employer |Date From: |Date To: |Job Title/Job Function/ Responsibilities: |Salary and Reason for | | | | | |Leaving | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Section 6 References | Please give the names and addresses of your two most recent employers (if applicable). If you are unable to do this, please clearly outline who your referees are. | |(NB. References will only be taken if you commence employment with us) | |Reference 1 | |Reference 2 | |Name: | |Name: | | Their Position (job | |Their Position (job title): | | |title): | | | | |Work Relationship: | |Work Relationship: | | |Organisation: | |Organisation: | | |Dates Employed: |From: ????? |To: ????? |Dates Employed: |From: ????? |To: ????? | Address: | |Address: | | | | | | | | | | | | | | | | | |Postcode | |Postcode | | |Telephone No: | |Telephone No: | | |E-mail: | |E-mail: | | Section 7 Declaration | | | |I confirm that the information provided in this application and within my Curriculum Vitae is both truthful and accurate. I have omitted no facts that could affect | |my employment. I understand that any false misleading statements could place any subsequent employment in jeopardy. I understand that any employment entered into is| |subject to documentary evidence of my right to work in the UK and satisfactory references. I expressly consent to personal data contained within this form being | |recorded for the purposes of assessing suitability for the post and may form the basis of any subsequent personnel file. | |Signed: | |Date: | | | | | |White Rose undertakes that it will treat any personal information that you provide to us, or that we obtain from you, in accordance with the requirements of the | |Data Protection Act 1998. After initial assessment, White Rose may keep your details on file pending suitable opportunities that may arise in the future. Please | |tick if you do not wish us to hold your details. | |Section 8 Recruitment Monitoring Form | | | |This sheet will be separated from your application form upon receipt and does not form part of the selection process.
It will be retained by the Human Resources | |purely for monitoring purposes. | |Application for the post of: | | |To help us ensure that our Equal Opportunities Policy is fully and fairly implemented please COMPLETE THIS SECTION OF THE APPLICATION FORM. | |What is your Ethnic Group? | |Choose ONE section from A to E, and then tick the appropriate box to indicate your cultural background. | |A. White | |D. Black or Black British | | |White UK | |Black Caribbean | |Irish | |Black African | | |White non-UK | |Any other Black background | | | | |(please give details): | | |Any other White background | | | | |(please give details): | | | | | | |B. Mixed | |E.
Chinese or other ethnic group | | |White & Black Caribbean | |Chinese | | |White & Black African | |Vietnamese | | |White & Asian | |Any other ethnic background | | | | |(please give details): | | |Any other Mixed background | | | | |(please give details): | | | | | | |C. Asian or Asian British | | I do not wish to provide this | | | | |information | | |Indian | | |Pakistani | | |Bangladeshi | |Any other Asian background | | |(please give details): | | | | |Section 8 Recruitment Monitoring Form continued | |Gender | |Male | |Female | | |Disability | |Disability is defined as “physical or mental impairment, which has a substantial and long term adverse effect on a person’s ability to carry out normal day to day | |activities”. | |Do you consider yourself disabled? |Yes | |No | | If yes, please give details: | | | |Age Group | |16-25 | |26-35 | |36-45 | | |46-55 | |56-65 | |66-70 | | |Over 70 | | |Media | |Please state where you saw this post advertised | | |
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