Mayfield Fellowship

MAYFIELD FELLOWSHIP

APPLICATION FOR EMPLOYMENT:

Registered Office: Mayfield Court

40 Youens Way

Liverpool, L14 2EP

Tel: 0151 283 9090/Fax: 0151 283 9091

CONFIDENTIAL

TO BE COMPLETED BY APPLICANT IN OWN HANDWRITING, PREFERABLY IN BLACK INK.

Mayfield Fellowship is an equal opportunities employer and will prevent discrimination particularly on the grounds of sex, disability, race, colour, religious belief, sexuality, nationality, ethnic origin, age, trade union activity, and responsibility for dependants or employment status.

TITLE: Mr/Mrs/Miss/Ms/Other (please state)…………………………….

SURNAME………………………………………………………………...

FIRST NAMES……………………………………………………………

ADDRESS…………………………………………………………………

……………………………………………………………………………..

TELEPHONE NO…………………………………………………………

NATIONAL INSURANCE NO: …………………………………………..

APPOINTMENT APPLIED FOR …………………………………………

PLEASE INDICATE HOW/WHERE YOU SAW THIS POST ADVERTISED E.G. NEWSPAPER/JOB CENTRE

(Please state name)………………………………………………………………….

ARE YOU RELATED TO ANYONE WHO WORKS HERE NOW OR IN THE PAST

YES/NO

If yes please give details ……………………………………………………………

DO YOU HAVE ANY PHYSICAL DISABILITIES WHICH COULD AFFECT YOUR ABILITY IN APPLYING FOR THIS POSITION?

YES/NO

If YES, please describe…………………………………………………………………

………………………………………………………………………………………….

Are you a registered disabled person? YES/NO

Do you hold a current driving licence? YES/NO

Have you applied to Mayfield Fellowship before? YES/NO

If so, when?……………………………………………………………………………..

EDUCATION

SECONDARY SCHOOL(S)……………………………………………………………

FROM……………………………………….TO………………………………………

EXAMINATIONS

Date Subject Result

1) …………………………………………………………………………………….

2) …………………………………………………………………………………….

3) …………………………………………………………………………………….

4) …………………………………………………………………………………….

5) …………………………………………………………………………………….

6) …………………………………………………………………………………….

7) …………………………………………………………………………………….

8) …………………………………………………………………………………….

OTHERS (please state as above)………………………………………………………

…………………………………………………………………………………………..

HIGHER EDUCATION………………………………………………………………..

FROM……………………………………..TO………………………………………...

Subject Qualifications

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EMPLOYMENT HISTORY – in chronological order

Dates:
From & To / Employer’s name, address & nature of business / Salary / Reason for leaving

PLEASE LIST BELOW (WITH AN EXPLANATION) ANY GAPS IN YOUR EMPLOYMENT HISTORY:

Dates: From & To / EXPLANATION

NOTICE DUE TO CURRENT EMPLOYER…………………………………………

INTERESTS:

Please give brief details of leisure activities and interests.

………………………………………………………………………………………………………………………………………………………………………………………………………………

Please explain why you have applied for this position.

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What previous experience do you possess which is relevant to the vacant position?

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Any Additional information.

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PERSONAL REFERENCES

Please give details of two persons (not relatives or friends) we could approach for references. Please include your latest 2 employers. If unable to provide 2 latest employers we will accept a reference from a reputable member of the community, ie, teacher, GP, bank manager.

Name………………………………………. Occupation ………………………………..

Address …………………………………………………………………………………………..

Tel No …………………………………….

Name………………………………………. Occupation ………………………………..

Address …………………………………………………………………………………………..

Tel No……………………………………

REHABILITATION OF OFFENDERS ACT 1974

(EXCEPTIONS) ORDER 1975

Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4 (b) of the Rehabilitation of the Offenders Act 1974, by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) order 1975, and you are therefore not entitled to withhold information about conviction 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 Fellowship.

Have you ever been convicted of a criminal offence, or are you at present the subject of criminal charges? YES/NO

If YES please give brief details………………………………………………………………

………………………………………………………………………………………………..

The Manager will request information from the Independent Safeguarding Authority (ISA) to confirm that your name is not included on a list of people who are not considered suitable to work with vulnerable adults

Please sign on completion of this form.

I declare that the facts set forth in this Application for Employment are, to the best of my knowledge, true and complete. False or incomplete information can invalidate any appointment offered.

Date………………………… Signature of Applicant………………………………………

Health & Welfare

To promote the health and wellbeing of both staff and residents at Mayfield Court and to demonstrate compliance with current legislation and contractual obligations of placing Authorities that staff require immunity to Hepatitis B and annually receive the Influenza Vaccination.

Could you please complete the following status.

Hepatitis B Vaccine Yes/No

Date of last vaccination. ………………………………….

Influezna Vaccine Yes/No

Date of last vaccination. ………………………………….

Please note this will not affect this application. Successful applicants will undertake a vaccination programme funded by Mayfield Fellowship.

Signed …………………………………………

Date …………………………………………

Staff docs: job application – REVISED October 2013 Page 1 of 7