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.
Date of Application Job Title Department
Surname/Family Name First Names Title UK National Insurance No. Date of Birth GenderMaleFemaleI 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 BritishBangladeshiIndianPakistaniAny other Asian background MixedWhite & AsianWhite & Black AfricanWhite & Black CaribbeanAny other mixed background Other Ethnic GroupChineseAny other ethnic group Black or Black BritishAfricanCaribbeanAny other Black background WhiteBritishIrishAny 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 sexYesNo Persons of the opposite sexYesNo Persons of the same and opposite sexYesNo Please indicate your religion or beliefAtheismBuddhismChristianityIslamJainismJudaismOtherI 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
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
Preferred Employment TypeFull-TimePart-TimeJob ShareFlexible Hours Do you have a valid driving licence for the UK ?YesNo
Include in this section all relevant qualifications. Please also indicate subjects currently being studied. Education 1
Education 2
Education 3
Education 4
Education 5
Include in this section any relevant training courses that you have attended or details of courses that you are currently undertaking. Training Course 1
Training Course 2
Training Course 3
Training Course 4
Training Course 5
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
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
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
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
