APPLICATION FORM

Please use BLOCK CAPITALS.

POSITION APPLIED FOR

Position applied for:

Date available:

For what salary are you looking?:

How did you hear about us?:



PERSONAL DETAILS

Surname:                                                                                  Forename (s):

Address:

Post Code:

Telephone (Home):                                                                   Mobile:

Date of Birth:

Marital Status:

General Health:

National Insurance No:

Nationality:

Work Permit (non EU citizens):   YES/NO

EDUCATION & TRAINING RECORD

Schools/Colleges Attended                                                       From                              To

 

 

Qualifications obtained




University/Polytechnic Attended                                               From                               To

 

 

Qualifications obtained




Membership of Professional Bodies







EMPLOYMENT HISTORY
Please state current/last employment first. 

If dates do not run consecutively, please state why:

 

If you are currently unemployed, please state why:



Employer:

Referee:

Address:

Telephone:

Job Title:

Employment started:                                                                 Employment finished:

Description of your role and responsibilities:




Reason for leaving:

Salary on leaving:


Employer:

Referee:

Address:

Telephone:

Job Title:

Employment started:                                                                 Employment finished:

Description of your role and responsibilities:




Reason for leaving:

Salary on leaving:


Employer:

Referee:

Address:

Telephone:

Job Title:

Employment started:                                                                 Employment finished:

Description of your role and responsibilities:




Reason for leaving:

Salary on leaving:


Employer:

Referee:

Address:

Telephone:

Job Title:

Employment started:                                                                 Employment finished:

Description of your role and responsibilities:




Reason for leaving:

Salary on leaving:


OTHER INFORMATION

Hobbies/Interests/knowledge of foreign language, certificates etc:






DECLARATION

The information I have given in this application is true and complete

Signed:

Date:

 

 

 

CONFIDENTIAL

MEDICAL QUESTIONNAIRE

Please complete the following questionnaire. This information is required with your interests in mind. As a result of the
information you have given, you may be referred to a doctor appointed by the company so that a medical examination
can be carried out. If you wish, you may request an interview with the company's medical officer/nurse,
either as an alliterative to completing this or to provide supplementary information or explanation.

Please answer either NO or YES to each question.  If the answer is YES, please give details.

A

Have you ever:

1. Had an operation?

2. Been seriously injured?

3. Received in-patient treatment for a physical or mental condition?

4. Been refused or dismissed from employment for health reasons?

5. Received a disability pension?

6. Been registered disabled?

    If YES, card no:                                                                      expiry date:

7. Been made ill by your work?

8. Been refused a drivers licence because of ill health?

B

Do you suffer from or have you ever had:
     Diabetes   YES/NO

     Skin rashes/Eczema   YES/NO

     Swelling of legs/ankles   YES/NO
     High blood pressure   YES/NO

     Anaemia   YES/NO

     Period/Prostate problems   YES/NO
     Asthma   YES/NO

     Headaches (frequent)   YES/NO

     Varicose veins   YES/NO
     Cough (frequent)   YES/NO

     Heart problems   YES/NO

     Rupture   YES/NO
     Rheumatic Fever   YES/NO

     Chest problems   YES/NO

     Back problems   YES/NO
     Arthritis   YES/NO

     Fainting or dizziness   YES/NO

     Ear problems   YES/NO
     Epilepsy/Fits   YES/NO

     Hay fever   YES/NO

     Eye problems   YES/NO
     Shortness of breath   YES/NO

     Jaundice   YES/NO

     Nerve problems   YES/NO

C 

Do you take medicine regularly?  YES/NO

Do you need glasses to read?  YES/NO

Have you worked in a dusty trade?  YES/NO

Have you ever had a head injury?  YES/NO

Do you suffer from any other ailments? YES/NO

DECLARATION

To the best of my knowledge and belief the information given above is correct. I understand that if
I am appointed and this information is inaccurate, I am liable for dismissal.

Signature:                                                                                Date:

Name: