Employment Application Form

Position Applied For

Surname:

Previous/Maiden Name:

First Names:

Sex:

E-mail Address:

Date Of Birth:

Present Address:

Nationality:

Home Telephone No:

Mobile Telephone No:

National Insurance No:

Do you hold a current driving licence ? YesNo

Licence Number (if Yes):

Licence Expiry Date:

Do you require a work permit to be employed in the UK ? YesNo

Emergency Contact/Next of Kin

Name:

Capacity in which this person is known to you:

Address:

Home Telephone No:

Mobile Telephone No:

Employment History (Please give the full details of work history for the previous ten years, explaining any significant breaks)

Name of Current Employer :

Address of Current Employer:

Responsibilities :

Position Held :

Current Salary :

Start Date :

End Date :

Previous Employer 1

Name of Previous Employer :

Address of Previous Employer:

Responsibilities :

Position Held :

Current Salary :

Start Date :

End Date :

Previous Employer 2

Name of Previous Employer :

Address of Previous Employer:

Responsibilities :

Position Held :

Previous Salary :

Start Date :

End Date :

Professional References

First Reference (Present/Most Recent Employer)

Name :

Position :

Employment Address:

Email :

Tel No :

May we approach this referee prior to interview? YesNo

Second Reference (Present/Most Recent Employer)

Name :

Position :

Employment Address:

Email :

Tel No :

May we approach this referee prior to interview? YesNo

Educational, Technical and Professional Qualifications

Educational Details 1

Name of College or University or Secondary School:

Was it Full Time or Part Time ?Full TimePart Time

Start Date :

End Date :

Courses/Subjects :

Exam Results/Grades :

Educational Details 2

Name of College or University or Secondary School:

Was it Full Time or Part Time ?Full TimePart Time

Start Date :

End Date :

Courses/Subjects :

Exam Results/Grades :

Rehabilitation of Offenders Act 1974

Have you ever been convicted of any criminal offence? YesNo

Do you have any criminal charges pending? YesNo

Please give the details, if the answer is ‘Yes’ to either of the above:

N.B. Any information disclosed will be taken into consideration but will not automatically prevent the progress of your application.
Please declare all criminal convictions, whether spent or not, charges, warnings and cautions.

Medical Details

Please answer the following questions by ticking the appropriate YES/NO. If the answer to any question is YES then please give details in the space provided below. It is your responsibility to inform us immediately if any of the following information changes. Have you ever had in your life, including childhood, any of the following?

DESCRIPTION OF ILLNESS

Heart/Circulation Illness/hypertension: YesNo

Blood Disorders e.g. Anaemia, Haemophilia: YesNo

Eye Disease/Injury or Defect: YesNo

Asthma, Hay Fever: YesNo

Bronchitis, Pneumonia, Pleurisy: YesNo

Tuberculosis: YesNo

Diabetes: YesNo

Epilepsy, Frequent Fainting Attacks: YesNo

Headaches, Migraine: YesNo

Psychiatric Treatment: YesNo

Dermatitis, Psoriasis, Eczema, Skin Sensitivities: YesNo

Chicken Pox: YesNo

Hearing Loss, Frequent Ear Infections: YesNo

Hepatitis / Jaundice: YesNo

Bladder Kidney Infection: YesNo

Gynaecological Problems, Painful Periods: YesNo

Gastric Ailments, Ulcer: YesNo

Back Pain, Sciatica or Deformities of the spine: YesNo

Varicose Veins: YesNo

Do you have any deformities which affect movements?: YesNo

Are you receiving any medication from a Doctor?: YesNo

Have you ever been treated at hospital?: YesNo

Are you registered Disabled Person: YesNo

Weight:

Height:

Please provide the Name and Address of your GP (General Practitioners):

I declare that all the following statements are true and complete to the best of my knowledge and belief. I hereby give Royacare Agency the permission to contact my General Practitioner to obtain further information should it be required.
Other details:

EQUAL OPPORTUNITY QUESTIONNAIRE

Royacare Agency aims to be an equal opportunity employer and recruitment agency and seeks to ensure that job applicants are interviewed and/or put forward for vacancies solely on the basis of merit, irrespective of race, disability, age, gender, in order to monitor the effectiveness of our policy. We request all job applicants to provide the information requested below.

Thank you for your co-operation. The information given is for statistical monitoring purposes only.

Candidate’s Name:

Please make sure that you read all the categories listed below and then, tick/ circle the appropriate code number:

I am female (11) YesNo
I am Male (12) YesNo
I consider myself to have a disability (13) YesNo

Note: According to the Disability Discrimination Act 1995. ‘Disability’ includes any physical or mental impairment which may have a substantial and/ or long term adverse effect on your ability to carry out some or all normal activities of the job for which you are applying.

Please make sure you read all the categories listed below and then tick the appropriate code numbers that best describe your ethnic origin. Ethnic origin could be the origin of your role bearers, so it is not necessarily the same as nationality.

I am white of European origin (14) YesNo

I am white of other origin (please specify) (15) YesNo

I am Asian
Of Indian Origin (16) YesNo
Of Pakistani Origin (17) YesNo
Of Bangladeshi Origin (18) YesNo
Of Chinese Origin (19) YesNo
Of other origin (please specify) (20)

I am Black
Of Caribbean origin (21) YesNo
Of African origin (22) YesNo
Of other origin (please specify) (23)

I am of another origin (please specify) (24)

Upload all requested documents. (Up to 10 documents may be uploaded)

General Data Protection Regulation (GDPR) Consent & Confidentiality Statement

The information that you provide on this form and that obtained from other relevant sources will be used to process your application for employment. The personal information that you give us will also be used in a confidential manner to help us monitor our recruitment process. We may disclose your information to carefully selected third parties who may process data on our behalf or any of our Clients for the purpose of ascertaining your suitability for a particular assignment. If you are appointed, the information will be used in the administration of your employment with us. We may also use the information if there is a complaint or legal challenge relevant to this recruitment process. We may check the information collected with third parties or with other information held by us. We may also use or pass them to certain third parties in order to prevent or detect crime or in other ways as permitted by law.

By completing this application form you agree to the processing of sensitive personal data, as [described above], in accordance with our registration with the Data Protection Commissioner.

I declare that the information set out in this form is true and correct. I understand and agree that if I submit any false or misleading information, this may result in any offer of employment with the Company being withdrawn, or, if already accepted, will lead to dismissal.

I hereby authorise Royacare Agency to collect all information it may require in connection with my application for employment.

You have the absolute unrestricted right to withdraw your consent at any time. There will be no repercussions because of your withdrawal and we will stop processing the data for which you have withdrawn your consent.

I confirm that I have read and understood the Conditions of Engagement offered by the Company and agreed to comply with them and to be bound by them.

I have no objection to my details being held on computer records and utilised by the company in pursuit of its legitimate business. I understand that my application is subject to the receipt of satisfactory references, DBS (Disclosure & Barring Service) checks, and my ISA (Independent Safeguarding Authority) Register status.

I agree to inform Royacare Agency of any changes to the information I have supplied.