Registered Office: Prospect House, Prospect Road, Cowes, Isle of Wight, PO31 7AD
Tel: (01983) 290718 Fax: (01983) 297926
E-mail: inquiries@carefirstiw.co.uk
Web: www.carefirstiw.co.uk
Registered Company No. 06730362

APPLICATION FOR EMPLOYMENT

Data Protection Act 1998
This form contains personal data as defined by the Data Protection Act 1998. It is being used by Carefirst IW Ltd for the purpose of recruitment. Carefirst IW Ltd must protect the information provided and ensure that it is not passed to anyone who is not authorised to see it.

Should the applicant request a copy of this document as a subject access request under the Data Protection Act 1998, the information will be provided.

"*" indicates mandatory.
APPLICATION DETAILS
Position applied for:*
 
Date of application:*
 
Where did you see this position advertised?:*
 
PERSONAL DETAILS
Title:*
 
Forename(s):*
Surname:*
Home address:*
Post code:
Telephone   Home:
Mobile: 
Date of Birth:
Nationality:
NI Number:
Are you a citizen of the EU or EEA?
Yes    No  
If no, do you have a work permit?
Yes    No  
DRIVING RECORD
Do you have a current, clean, FULL driving licence?
Yes    No  
If yes, for what classes of vehicles?
If no, what penalties are displayed?
Please complete all fields in this section. Employment history must be stated in full. Any gaps in employment must be accounted for, please use Extra Employment Details, below, for this.
CURRENT/LAST EMPLOYMENT
Name of employer:
Company name:
Address:
Post Code:
Contact telephone number:
Position Held:
Main role/responsibilities:
Reason for leaving:
PREVIOUS EMPLOYMENT
Name of employer:
Company name:
Address:
Post Code:
Contact telephone number:
Position Held:
Main role/responsibilities:
Reason for leaving:
PREVIOUS EMPLOYMENT
Name of employer:
Company name:
Address:
Post Code:
Contact telephone number:
Position Held:
Main role/responsibilities:
Reason for leaving:
PREVIOUS EMPLOYMENT
Name of employer:
Company name:
Address:
Post Code:
Contact telephone number:
Position Held:
Main role/responsibilities:
Reason for leaving:
EXTRA EMPLOYMENT DETAILS
GENERAL EDUCATION
Name of School
From
To
Name of College/University
From
To
QUALIFICATIONS OBTAINED
REHABILITATION OF OFFENDERS ACT, 1994
Through the 1975 Exemptions Order of the Rehabilitation of Offenders Act 1974 and by virtue of the nature of the post for which you are applying, we are obliged, as your prospective employer, to ask the following question. Any information supplied by yourself will remain confidential and will be considered only in relation to the Job Application;

With the exception of minor motoring offences (i.e. Speeding tickets), have you ever been convicted or received a caution on any criminal offence by a Court of Law?   Yes   No

If "yes", please provide brief details of the offence(s) and relevant dates:
The employer is required to obtain a CRB and/or POVA on all potential employee applications

Please note, failure to mention any cautions or convictions at this stage of recruitment may result in offers of employment being retracted.
It is Carefirst IW Ltd policy to interview disabled applicants who meet the essential requirements of the post, for this reason it is necessary to ask the following actions.
HEALTH AND DISABILITIES
Do you class yourself as disabled under the terms of the Disability Discrimination Act 1995?   Yes   No

If "yes", please state disability registration terms and if you are registered disabled:
Do you have any health or disabilities which may be relevant to this job application   Yes   No

If "yes", please state them:
GENERAL HEALTH STATUS
 
EXCELLENT
GOOD
POOR
COMMENTS
Overall state of health:
Hearing:
Eyesight:
Please give details of any medical condition(s) for which you have received treatment in the past 5 years:
Have you had treatment for any condition relating to the abuse or misuse of drugs or alcohol within the last 5 years?
Yes   No

If "yes", please provide brief details of the offence(s) and relevant dates:
It may be necessary to request an independent medical examination during the application process or if you were successful , during your employment with Carefirst IW Ltd. Would you be willing to have an independent medical examination if required?   Yes   No

If "yes", please provide brief details of the offence(s) and relevant dates:
EQUAL OPPORTUNITIES - VOLUNTARY INFORMATION
The organisation seeks to recruit employees on the basis of their general suitability for a position and aims to ensure that consideration of age, sex, marital status, disability and racial or ethnic origin should play no part in the process.
In order to monitor the effectiveness of this commitment to equal opportunities it would be helpful if you could complete this section of the form. Completion is not compulsory but should you give details below the information will be used for no other purpose than as stated in this paragraph.

Marital Status:   Single    Married    Separated    Widowed    Divorced 

Sex:   Male    Female    Date of Birth: 

Ethnic Origin:   African    Afro-Caribbean    Asian    European    Polynesian 
ABOUT YOU
Please tell us about yourself and why you are interested in this position:
The employer must obtain two references before an offer of employment can be made. We require the name, address and contact details of two people who have knowledge about your work. One of these references should preferably be from your present or most recent employer. A character reference is acceptable if your current or most recent employer is stated.
REFERENCES
CURRENT/RECENT EMPLOYER REFERENCE
CHARACTER REFERENCE
 
Employer Name:
 
Company Name:
 
Address:
 
Post Code:
 
Contact telephone number:
 
Term of employment:
 
Your job role:
 
 
Employer Name:
 
Company Name:
 
Address:
 
Post Code:
 
Contact telephone number:
 
How long have they known you:
 
Your job role:
 
 
DECLARATION - PLEASE READ CAREFULLY, ENTER NAME, DATE AND SUBMIT YOUR APPLICATION
I confirm that the information that I have provided and understand that misleading statements may be sufficient grounds for cancelling any arrangements made. I also understand that questions left unanswered may be discussed at interview(s) arrising from this application.


Applicants name:   Date: dd/mm/yyyy