Employment Application Form

Name:*

First NameLast Name (Maiden Name)

Birth Date

DayMonthYear

Phone Number:*

Phone Number

E-mail Address:

Address:*

Street Address

Street Address Line 2

City

Postal / Zip Code

How were you referred to us?*

Other:

Do you hold a current driving licence?

Under the Terms of the Disability Discrimination Act 1995 which defines disability where he/she has a physical or mental impairment which has substantial and long-term effect on his or her ability to carry out normal day to day activity. Based upon the above definition have you currently or in the past had a physical or mental impairment which has a substantial and long-term adverse effect on your ability to carry out normal day to day activity?

Yes/No

Are you a registered Disabled Person?

If YES please state your R.D.P. Number

R.D.P Number

How many days absence due to illness have you had in the past twelve months

Days

Is your application for Full-Time or Part-Time employment:

Please state what hours you are avaialble to work?

NightsDays

Please give details of any holiday commitments:

How much notice must you give your present employer:

Weeks

If Yes, please give date(s)

Upload CV:

Upload a File

Upload Photo

Browse Files

Passport or similar style photo

Job Skills & Training

Describe your skills:*

GCSE or Equivalent / 'A' Levels or Equivalent (Grade/Year)

List Qualifications

Further Education

List Qualifications

Training or Certifications:

Qualified Staff Only:

Please include details of your professional qualifications

Where did you train?

What qualification did you gain?

On which part of the N.M.C Register are you registered?

Initial Date of Registration

Date

Pin No:

Expiry Date

Date

Do you have any pending N.M.C proceedings?

If yes please give details:

Rehabilitation of Offenders Act

Because of the nature of the work for which you are applying, this position is exempt from the provision of Article 5 of the Rehabilitation of Offenders (N.I) Order 1978 and by virtue of the Rehabilitation of Offenders (Exceptions) Order (NI) 1979

Applicants are therefore not entitled to withhold information about convictions which for other purposes are "spent" under the provisions of the Act and in the event of employment any failure to disclose such convictions could result in disciplinary action including dismissal by the employer. Any information given will be treated in the strictest of confidence and will be considered in relation to this application.

Have you ever been convicted of a criminal offence by a court of law (with the exception of minor motoring offences or offences committed as a juvenile under the age of 16)?

Yes/No?

If yes please give details including the offence and the date:

Signed as a correct statement:

Date

Career

Please list your previous employers and job details.

Name and Address of Employer Name
   Address Line 2   City    Postcode
Position Held: Position
From:   Date   To:   Date   i
Reason for leaving:   Reason
Final Salary:   £

References

Please give the Names, Addresses and Telephone Numbers of two people who may be contacted to provide references one of whom should be your last or current employer, relatives should not be used.

Reference 1 - Last Employer

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Email

example@example.com

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

PostCodeCountry

Reference 2 - Character, Integrity, Personality

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Email

example@example.com

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

PostCodeCountry

Please describe why you want this job:

How would you describe your character and personality?

Please use this space for details of any other information which you may feel would support your application and which you may consider relevant:

I confirm that the information given is accurate and I understand that any false information or deliberate omissions may disqualify me from employment or may render me liable to disciplinary action including dismissal.

Signature

APPENDIX 1

INFORMATION ABOUT AND CONSENT TO THE PROTECTION OF CHILDREN (POC) (NI) AND/OR VULNERABLE ADULTS (POVA) (NI) SERVICE/SCHECK BY APPLICANTS FOR POSTS INVOLVING WORK WITH CHILDREN AND/OR VULNERABLE ADULTS

You have applied for a post which is governed by The Protection of Children and Vulnerable Adults (Northern Ireland) Order 2003. Before appointing anyone to such a post, it is our policy to ask for the relevant check to be carried out by Access NI. This check is to make sure that individuals who might be a risk to children and/or vulnerable adults are not appointed.

The check will tell us if you have a criminal record, or if your name is included on the DHSSPS Disqualification from Working with Children List or included on the DE List and/or the DHSSPS Disqualified from Working with Vulnerable Adults List. Any information received will be treated confidentially, and we will talk to you about it before a final decision is reached. After the decision is made the information will be destroyed. (Employment/Nursing Agencies and Employment Businesses will retain this information for 12 months).

A check will only be carried out if you are considered to be the preferred candidate and are being offered an appointment. You must tell us now if you have ever been convicted of a criminal offence, or cautioned by the police, or bound over. You must tell us about all offences, even minor ones such as motoring offences, and 'spent' convictions, that is, things which happened a long time ago. If you leave anything out it may affect yom application.

Please complete the section below and return it with your application. The form also asks you to give your written consent to the check. If you do not consent we will not accept your application.

CONSENT TO (check all that apply)

Access NIPOC (NI) CheckPOVA (NI) Check

Do you have any prosecutions pending?

If yes please give details

Have you ever been convicted at a court or cautioned by the police for any offence?

If yes, please list below details of all convictions, cautions, or bind-over orders. Give as much information as you can, including, if possible, the offence, the approximate date of the court hearing and the court which dealt with the matter.

Have you ever been the subject of an Adult or Child Abuse investigation?

If yes please give the full details below. If possible please provide the approximate date/s

Signature

Date

Position Applied For

Confidential Medical Questionnaire

Are you currently receiving medical treatment?

YesNo

Have you ever had a chest x-ray?

YesNo

If yes, please state when and what was the result?

Please tick if you have suffered from any of the following:

Have you ever had any form of serious illness or operation?

YesNo

Do you have a sight defect?

YesNo

If yes, do you wear glasses?

Do you have a hearing defect?

YesNo

If yes, do you wear a hearing aid?

Have you any infection of your skin, ear, throat, nose, or bowel?

YesNo

If you have answered yes to any of questions 1, 3, 4 or 7 please give a detailed description as to the nature of the illness/treatment and include dates

Have you had any sickness extending over 3 days in the last 2 years?

YesNo

If yes, please state the number of periods and the dates and durations as well as the nature

Name and address of your doctor:

I declare that to the best of my knowledge my answers to the above questions are correct and I am not suffering from any illness of which I have not revealed. I would also like to confirm I am medically fit to undertake the work I have applied for

APPENDIX 2

Monitoring Information

We are committed to equality of opportumity for all job applicats regardless of sex, disability, marital status, race, religious affiliation or political opinion.

In order to facilitate the monitoring process, you are requested to complete the following questionnaire by making the appropriat selection below. The information provided is treated in strict confidence:

Sex

Marital Status

Are you a registered disabled person?

Under the terms of the Disability Discrimination Act 1995, a person has a disability if he/she has had a physical or mental impairment which has a substantial and long term, adverse effect on his/her ability to carry out normal day to day activities.

Do you consider that you are a disabled person in line with the above definition?

Religious Affiliation

Ethnic Origin