HR Recruitment REC 04b– Application Form

Revitalise Confidential Application for Employment

(This appointment is subject to an enhanced CRB/POVA check)

Position applied for:

Personal details

Surname
Forenames
Title
Address
Postcode
Telephone no / Home
Business
Mobile
e-mail address
N I Number

Are you eligible to work in the UK? YES / NO

Have you ever been convicted of a criminal offence? (Declaration subject to the Rehabilitation of Offenders Act): YES / NO
If yes, please supply details. (You should include details of any convictions which are spent within the meaning of section 1 of the Rehabilitation of Offenders Act 1974(b) which may be disclosed by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, and any cautions you may have received.)
Regardless of the outcome, at any time, have you ever had any allegation or investigation of abuse made against you? YES / NO
(If yes, please supply full details)
If offered this position, do you intend to continue working in any other capacity? YES / NO (If yes, please supply full details)
Are you related to or have a personal relationship with a member of staff or a trustee of Revitalise? YES / NO
If yes, please supply further details
Where did you hear about this vacancy?
Local paper
Websearch
Agency
Word of Mouth

Please describe, in no more than two sides of A4 paper, how you meet the requirements of the job description and person specification for this role. Please use a separate sheet if required.

Education

Schools attended from age 11 / From/To / Examinations (subjects / results)
Dates (approx.)
Further education and training / From/To / Examinations (subjects / results)
Dates (approx.)
Professional qualifications. (Please include Nurse PIN number if appropriate.)

Employment History (Please supply full details for the ALL previous employment. Please copy and use continuation sheet/s if necessary).

Except in exceptional circumstances Revitalise will require a minimum of 2 references from previous employers. If you are unable to provide this information please detail in cover letter.

Present / last employer:
Starting date: leaving date
Address:
Email:Telephone:
Job title:
What were you required to do?
Reason for leaving:
Finishing pay
Reference: Yes / No
Present / last employer:
Starting date: leaving date
Address:
Email:Telephone:
Job title:
What were you required to do?
Reason for leaving:
Finishing pay
Reference: Yes / No
Present / last employer:
Starting date: leaving date
Address:
Email:Telephone:
Job title:
What were you required to do?
Reason for leaving:
Finishing pay
Reference: Yes / No

I confirm that the information given on this form is, to the best of my knowledge, true and complete. Any false statement may be sufficient cause for rejection or, if employed, dismissal.

Signature: ______

Date: ______

Employment Information – Continuation sheet number ( )

Present / last employer:
Starting date: leaving date
Address:
Email:Telephone:
Job title:
What were you required to do?
Reason for leaving:
Finishing pay
Reference: Yes / No
Present / last employer:
Starting date: leaving date
Address:
Email:Telephone:
Job title:
What were you required to do?
Reason for leaving:
Finishing pay
Reference: Yes / No
Present / last employer:
Starting date: leaving date
Address:
Email:Telephone:
Job title:
What were you required to do?
Reason for leaving:
Finishing pay
Reference: Yes / No

I confirm that the information given on this continuation sheet is, to the best of my knowledge, true and complete. Any false statement may be sufficient cause for rejection or, if employed, dismissal.

Signature: ______

Date: ______

All information supplied is confidential and will be considered in relation to applications for employment.

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