HOMELINK CAITHNESS APPLICATION FOR EMPLOYMENT

Position Applied for

Date of Application

Location

Source of application (name of newspaper, journal, job centre or other)

To be completed in applicants own handwriting

Surname Name before marriage Place of birth

Date of Birth Dr/Mr/Mrs/Miss/Ms Forenames Marital Status

Full Address

Do you require a U.K. work permit? Yes No

Do you hold a valid driving licence? Yes No

Are you on the Disabled Persons Register: Post Code Yes No

Telephone Number

If so, please give your Registration Number.

EQUALITY IN EMPLOYMENT The policy of HomeLink Caithness is to provide equal opportunity to all members of staff and to ensure that no member of staff or applicant for employment is disadvantaged by conditions or requirements which cannot be shown to be justified. The promotion of equal opportunity will be actively pursued through the application of employment policies, which will ensure the individuals receive treatment, which is fair, equitable and consistent with their skills and abilities. We should be most grateful if you would provide this information to help us monitor the effectiveness of our equal opportunities policy. I would describe my ethnic or cultural origin as: Black A B AFRO-CARIBBEAN AFRICAN C D ASIAN OTHER* White E F EUROPEAN OTHER*

(Please tick appropriate box) (*Please specify) The categories and definitions of ethnic or cultural origins used above are those accepted by the Commission for Racial Equality. Yes No

Have you ever been convicted of any offence before a Court of Law?
If Yes, please give details

Education and Training

Name and Location Examinations Passed or to be Taken (with grades and names of courses studied)

Schools

Colleges

Other Education and Training

Please give details of any other specialised training you have undertaken.

Membership/Grade of professional institutions

Employment Information
Have you applied for a position with HomeLink Caithness before? If Yes please give details, including dates.

Yes

No

Employment is subject to Disclosure Scotland and satisfactory references being received. In this respect two references are required from previous employers including your current/most recent employer. We will only contact these referees if we offer you employment . 1. 2.

Present or Last Appointment

Employers (name and address) Date employment began Date employment finished

Current or last salary

Employers type of business

Positions held

Duties

Period of notice (or date of leaving) Reason for leaving/ wishing to leave

Name and address of employer

From

To

Position held

Reason for leaving

Please tell us about any attributes /skills that you feel you can bring to this position, or about any voluntary work you may have undertaken

I confirm that the information given on this application form is correct. Signature:

__________________________________

Date:______________________

Medical Questionnaire

1.

In general, is your health good? If no, please give details

Yes

No

2.

How many days have you been absent from work/school/college due to sickness or injury in the last year?

3.

Have you consulted a Doctor at any time over the last five years for anything other than minor illness? (e.g. cold, flu, etc)

4.

Are you presently taking any medication? (other than contraceptives?)

Yes

No

Are you currently receiving or on a waiting list to receive any medical treatment? If, Yes, please give details

Yes

No

6.

In the last five years have you suffered from: Yes No Back Problems Fainting or dizziness Skin Disorders Stomach upsets Migraine

Yes No

Yes No Severe headaches Epilepsy / Blackouts or fits Vertigo Heart disorders

Depression/anxiety/stress Chest/Respiratory Infections Gynaecological problems

Notice to Applicant If you answer Yes to any of questions 3 6 you will not automatically be excluded from employment with HomeLink Caithness. However, we may investigate your answers further and may require either contact with your G.P. (with your express written permission) for evidence of satisfactory health. We need to know you are able to carry out the duties as per the job description, taking into account any obligations we have under the Disability Discrimination Act. As a condition of Employment you are required to answer the above honestly and to the best of your knowledge and belief. Misrepresentation or deliberate omission is a dismissible offence under our disciplinary procedure. This application form will form part of your written statement of particulars of employment, which is your contract of employment with this company. False or withheld information may lead to termination of employment.

Statement by applicant I have answered the above questions honestly to the best of my knowledge and belief.

Signature:

__________________________________

Date:______________________