CHINESE MENTAL HEALTH ASSOCIATION

Chinese Mental Health Association

Please complete this form using block capitals and return to usprior to the application deadline to:

2/F Zenith House, 155 Curtain Road, London, EC2A 3QY

Position Applied For: / Social Club Co-ordinator
Closing Date: / 08thSeptember 2011

Part 1:Personal Details

Surname (in Block capitals): / Mr/Mrs/Ms/Miss
Other (Please specify)
Forenames:
Full Address: / Postcode:
Telephone No.: / Day:
Evening:
Mobile:
Email Address:
Nationality:
Do you require a work permit to work in the UK? / YES / NO
Where did you see this vacancy advertised?
When can you start?
Are you in good health? If not, please state why:
Have you a disability which requires the provision of specific facilities at interview or for work? If so, please provide details.
Languages: / Written:
Spoken:

Part 2:Education and Training(Please start with most recent)

Secondary Education
(Names of schools, colleges etc, attended and location) / Date:
(From/To) / Subject / Grade
Higher Education
(Names of University / Institution, Location) / Date:
(From/To) / Qualification
(e.g. BSc, MSc etc.) / Subject: / Grade: / Date:
Professional Memberships:

Part 3:Employment History(Please start with most recent)

Name and address of employer / Name of Company:
Address:
Postcode:
Job Title / Grade and Salary
Date Started / Date Finished
(if applicable)
Notice Period
Summary of duties

Previous Employment

Date
(From / To) / Name & Address of Employer / Position Held / Grade / Salary / Reason for leaving

Part 4:Supporting Statement

Details of your experience, skills and any additional information you wish to submit in support of your application (you may attach additional sheets if the space provided is insufficient)

Part 5:Interests and Hobbies

Part 6:Referees (Please supply details of two referees, one of whom should be your present/most recent employer)

Referee One:

Name:
Title: / Mr/Mrs/Ms/Miss
Other (Please specify)
Occupation:
Name and address of Company/Organisation:
Telephone Number:
Email Address:

Referee Two:

Name:
Title: / Mr/Mrs/Ms/Miss
Other (Please specify)
Occupation:
Name and address of Company/Organisation:
Telephone Number:
Email Address:

May we obtain reference from your present employer before a firm offer of employment is made? YES / NO

Convictions

Do you have any criminal convictions, which are unspent under the Rehabilitation of Offenders Act 1974? If so, please specify. / YES / NO

Part 7:Declaration

I hereby declare that all information provided on this application form is true and accurate to the best of my knowledge. I understand that deliberately falsifying or withholding information could at a later date be grounds for dismissal. I agree that the information given on this form may be used for registered purposes under the Data Protection Act, 1984.

Applicant’s name:______

Signature:______

Date:______

Thank you for completing the application form.

Please return to CMHA at the address specified below.

Chinese Mental Health Association

2/F Zenith House

155 Curtain Road

London EC2A 3QY

Registered Charity no. 1058934 Company Limited by Guarantee No. 3150505

Chairman:Shun Au OBE

Telephone:020 7613 1008

Fax:020 7739 6577

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Job Application Form