Application Form

    Please fill in this Application Form; it is split into two parts: Part A and Part B. Please fill in both parts of the form and check it carefully before sending. Please note that questions marked with an asterisk ‘*’ are mandatory and therefore must be answered.

    APPLICATION FOR EMPLOYMENT – PART A

    Date of Application

    Job Title

    Department

    Personal Details

    Surname/Family Name

    First Names

    Title

    UK National Insurance No.

    Date of Birth

    Gender
    MaleFemaleI do not want to disclose my gender
    Address

    Email address

    Post Code

    Country

    Home Telephone

    Mobile Telephone

    Work Telephone

    May we contact you At work ?

    Do you need a UK work permil to do this job under the terms of the Immigration and Asylum Act 1996 ?
    No, I do not need a UK work permitYes, I need a UK work permitNo, I have a UK Training & Work Experience permit
    Details of any permit currently held:

    Are you a Department of Work & Pensions New Deal candidate ?
    YesNo

    Equal Opportunities Monitoring

    Race Relations (Amendment) Act 2000

    As Private Sector Employers, Hengoed Park is required to collect details about an applicant’s ethnicity. This information is collected to fulfil that obligation and is used for monitoring purposes only.

    I would describe my ethnic origin as follows:-
    Asian or Asian British
    BangladeshiIndianPakistaniAny other Asian background
    Mixed
    White & AsianWhite & Black AfricanWhite & Black CaribbeanAny other mixed background
    Other Ethnic Group
    ChineseAny other ethnic group
    Black or Black British
    AfricanCaribbeanAny other Black background
    White
    BritishIrishAny other White background

    Employment Equality Regulations 2003

    In order to comply with these regulations Hengoed Park Employers are monitoring sexual orientation and religion/belief in applications.

    * Do you have a sexual orientation towards:-
    Persons of the same sex
    YesNo
    Persons of the opposite sex
    YesNo
    Persons of the same and opposite sex
    YesNo
    Please indicate your religion or belief
    AtheismBuddhismChristianityIslamJainismJudaismOtherI do not wish to disclose my region

    Disability Discrimination Act 1995

    Under the terms of the Act a disability is defined as a ‘physical or mental impairment which has a substantial and long term effect on a person’s ability to carry out normal day to day activities’.
    * Do you consider yourself disabled ?
    YesNoUndisclosed
    If yes, do you need special arrangements to enable you to attend for interview ?
    YesNo
    If so, please give details


    Rehabilitation of Offenders Act

    In order to protect certain vulnerable groups within society, there are a number of posts and professions that are exempt from the provisions of the Rehabilitation of Offenders Act 1974. These include posts where, in the normal course of their duties, successful applicants will have access to persons in receipt of health services. If the post you have applied for falls within the above category, it will be exempt from the provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act (Exceptions Order) 1975.
    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 dismissal or disciplinary action by the employing organisation. Any information given will be confidential and will be considered only in relation to posts to which the order applies.

    * Have you at any time received, or had Pending, a court conviction ?
    YesNo
    If so, please give details:-


    If you are applying for a post involving access to persons in receipt of health services, your offer of employment
    may be subject to a satisfactory disclosure from the Criminal Records Bureau. Failure to reveal information relating
    to any convictions could lead to withdrawal of an offer of employment.

    DECLARATION

    The information in this form (parts A&B) is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation.
    This applies equally to any medical questionnaire/forms I may complete.
    I agree to the above declaration
    Yes

    APPLICATION FOR EMPLOYMENT – PART B

    Details entered in this part of the form will be held in the HR department of the recruiting organisation and will be made available to the management team.
    Date of Application

    Job Title

    Department

    Additional Personal Information

    Preferred Employment Type
    Full-TimePart-TimeJob ShareFlexible Hours
    Do you have a valid driving licence for the UK ?
    YesNo

    Education & Professional Qualifications

    Include in this section all relevant qualifications. Please also indicate subjects currently being studied.
    Education 1

    Subject/Qualification
    Place of study
    Grade/Result
    Year

    Education 2

    Subject/Qualification
    Place of study
    Grade/Result
    Year

    Education 3

    Subject/Qualification
    Place of study
    Grade/Result
    Year

    Education 4

    Subject/Qualification
    Place of study
    Grade/Result
    Year

    Education 5

    Subject/Qualification
    Place of study
    Grade/Result
    Year

    Training Courses Attended

    Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking.
    Training Course 1

    Course Title
    Training Provider
    Duration
    Date completed

    Training Course 2

    Course Title
    Training Provider
    Duration
    Date completed

    Training Course 3

    Course Title
    Training Provider
    Duration
    Date completed

    Training Course 4

    Course Title
    Training Provider
    Duration
    Date completed

    Training Course 5

    Course Title
    Training Provider
    Duration
    Date completed

    Employment History

    Please record below the details of your current or most recent employer.
    Employer Name

    Address

    Type of Business

    Telephone

    Job Title

    Start Date

    End Date

    Grade

    Reporting to (Job Title)


    Salary

    Reason for leaving (if applicable)

    Description of your duties and responsibilities

    Previous Employment

    Please record below the details of your previous employment beginning with the most recent first. Please explain any gaps in employment in the “Supporting Information” section below. Please add additional employers/information on a separate sheet.

    Previous Employer 1
    Employer Name

    Address

    Job Title

    Grade

    From Date

    To Date

    Reason for leaving

    Description of your duties and responsibilities

    Previous Employer 2
    Employer Name

    Address

    Job Title

    Grade

    From Date

    To Date

    Reason for leaving

    Description of your duties and responsibilities

    Previous Employer 3
    Employer Name

    Address

    Job Title

    Grade

    From Date

    To Date

    Reason for leaving

    Description of your duties and responsibilities

    Supporting Information

    In this section please give your reasons for applying for this post and additional information which shows how you match the person specification for the job (you will have been sent this document with this application form). This
    can include relevant skills, knowledge, experience, voluntary activities and training etc.,
    Supporting information

    References

    Please give the names of the people who have agreed to supply references. For all positions you must provide 2 references. If you are, or have been, employed these should be your two most recent employers. These may include your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. If you are a student please provide contact details of a teacher at your school, college or university. All referees will be approached prior to interview unless you indicate otherwise.

    Referee 1
    Name

    Job Title

    Address

    Postcode

    Country

    Telephone

    Fax

    Email

    Relationship

    Can the referee be approached prior to the interview ?
    YesNo

    Referee 2
    Name

    Job Title

    Address

    Postcode

    Country

    Telephone

    Fax

    Email

    Relationship

    Can the referee be approached prior to the interview ?
    YesNo

    Referee 3
    Name

    Job Title

    Address

    Postcode

    Country

    Telephone

    Fax

    Email

    Relationship

    Can the referee be approached prior to the interview ?
    YesNo