APPLICATION FORM 26 Post applied for: Ref No: Closing date

APPLICATION FORM 26
Please complete in type or black ink
Post applied for:
Ref No:
Closing date:
Please note: If you have not heard from us, you should assume that your application has
been unsuccessful.
1
Personal Details
Full Name…………………………………………………………………………………………
Address………………………………………………………………………………………………
…………………………………………………………………………………………………………
Telephone No Work ………………………..............Home………………………......................
Mobile No………………………………………………Email……………………………………....
I need a permit to work in this country
Yes
No
National Insurance number………………………………………………………………………
2
Current or most recent employment
Name of Employer……………………………………………………………………....................
Address………………………………………………………………………………………………
…………………………………………………………………………………………………………
Telephone………………………………Notice Required…………………………………..........
Position held………………………………………………Date appointed……………………...
Grade………………………………………..Salary/Wages………………………………………
…
Please describe briefly the main duties
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
.................................................................................................................................................
1
3
Previous employment
Start with your most recent job. Please account for all time (paid and unpaid) since leaving
school, college or university including any gaps in employment.
Name of
employer/organisation
And full address
Job Title
From
Mth/Year
From
Mth/Year
Reason for
leaving
4
Relevant education, qualifications and training
Please give details professional education, further education and secondary education.
Please indicate the duration of your course and where you studied. You can also include
any relevant short courses you have attended. Please start the list with your most recent
qualifications.
Title and subjects
5
School, College or University
Dates
PIN/Registration Number
Please give details of your registration number. Please note that we may check this
number with the relevant awarding bodies/institutions.
6
Supporting statement
Drawing upon your experience, knowledge, skills and abilities, explain how you fulfil the
requirements set out in the person specification. Experience may have been gained
through paid or voluntary work or in the home. (Please continue on separate sheet if
necessary).
7
References
Please give the names and addresses of two people who can verify your employment
record. One should be your present/most recent employer. If you have not been in paid
employment, please give the head of education or training establishment and/or the
manager of a voluntary group for whom you have worked.
Referee details
Name
A
Referee details
Name
Position
Position
Business Address
Business Address
Tel No.
Tel No.
Relationship to applicant
Relationship to applicant
B
ll
6
Please indicate by placing an X in the box above if you do NOT want your referee’s to be
7approached
References
prior to any interviews.
8
Disclosure of Convictions
The post you have applied for is excluded from the provisions of the Rehabilitation of Offenders Act
1974 as amended by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as
amended. You must therefore disclose details of all convictions, cautions and bind over orders
whether spent or not; and whether imposed when you were an adult or a juvenile. You must also
disclose details if you are currently the subject of a police investigation/proceedings which could
result in a conviction, caution or bind over order.
We appreciate that you may feel embarrassed about having to declare such matters, but you will be
given full opportunity to explain the circumstances of any conviction, caution or bind over order and it
is possible that these will not exclude you from appointment.
Failure to disclose fully any conviction, cautions or bind over order may lead to disciplinary action
up to and including dismissal.
Have you ever been convicted of a criminal offence, or are you at present the subject of
criminal charges?
YES
NO
If yes, please give details (continue on a separate page if necessary):
DATE
COURT
OFFENCE
PENALTY
9
Disqualification from caring for children
Have you ever been disqualify from caring for children? You should be aware that an
individual who is disqualified from working with children is guilty of an offence if he
knowingly applies for, offers to do, accept or does any work in a regulated position.
YES
NO
If yes, please give details (continue on a separate page if necessary):
DATE
10
COURT
OFFENCE
PENALTY
Known relationship
Are you related directly or indirectly to anyone currently or previously employed by Abronah
Care limited, or do you know anyone currently working for the company.
YES
NO
If yes, please give details (continue on a separate page if necessary):
NAME
RELATIONSHIP
POSITION
REMARKS
11
Declaration
If you omit information that we have asked for, we may not be able to consider your
application. If you are appointed to the post, any omission or inaccurate information
relevant to your application could lead to disciplinary or in some circumstances legal action
against you.
I confirm that to the best of my knowledge, the information given on this form is true
and accurate and I have not omitted any facts which may have a bearing on my
application
Signed……………………………………………………….Date…………………………………
FOR OFFICE USE ONLY
Short listed YES / NO Interviewed YES / NO
(if no reason)
(if no reason)
Appointed YES / NO
(If no reason)
Initials
Initials
Initials
Comments
I
A = Not met essential criteria
B = Not met desirable criteria
C = Other (Please specify)
12
Equal Opportunities monitoring
Abronah Care Ltd wishes to ensure there is genuine equality of opportunity in employment.
We collect the following information to monitor the success of our equality initiatives. The
panel making the appointment will not see this information.
Post applied for...........................................Ref no................................................
Last Name………………………………………………Initials……………………………………
Date of birth……………………………………………….
Where did you see this post advertised……………………………………………………………
About You
1.
I am
Male
2.
I would describe my ethnic origin as:
Female
White (excluding Irish)
Pakistani
Irish
Bangladeshi
Black Caribbean
Chinese
Black African
Asian
Black other
Other (Please specify)
Indian (Incl. E African)
PLEASE RETURN THE COMPLETE APPLICATION FORM TO:
Abronah Care Ltd
1st Floor
3 Trinity Road
Aston
Birmingham
B6 6AH
Tel: 0121 554 9077