The Cornwall Blind Association

iSightCornwall

The Sight Centre, Newham Road, TruroTR1 2DP

01872 261110

(Please type or print in black pen using additional sheets if necessary) CONFIDENTIAL

POSITION:-

CLOSING DATE:-

Surname: / Title:
Forename(s):
Address:
Telephone No. (Home) Tel No. (Day)

EDUCATION in chronological order starting from secondary school

Dates From - To / School/college/university / Qualifications

FURTHER COURSES/TRAINING

Dates From - To / Course / Certificate/Award/Diploma

INTEREST IN THE POST

Please state briefly why you are interested in the position, and what skills and experience you would bring to it, drawing attention to aspects of your career, interests and activities etc.

HEALTH

Are you in good health?
How many days sick leave have you had in the past 12 months

CRIMINAL CONVICTIONS

Have you ever been convicted of
a criminal offence? / If yes, details may be required in strict confidence.

DISCIPLINARY PROCEEDINGS

Are you presently or have you in the past been the subject of disciplinary proceedings in any employment? / If yes, you may be invited to provide further details.

REFERENCES

Please give names and addresses of two referees, one at least should be your present or most recent employer. If you would prefer us to contact your employer after an interview, please indicate.

1. (Current or most recent employer)
Contact before / after interview (please delete that which does not apply)
2.

EMPLOYMENT RECORD

Name & Address of present or most recent employer:
Date of joining and
leaving (from - to): / Job Title:
Summary of duties:
Reason for leaving:
Leaving Salary: / If you were offered the job, how soon
after notification could you start?

PUBLIC DUTIES OR SOCIAL ACTIVITIES

Please give details of any public duties and/or activities with voluntary organisations that you perform.

PREVIOUS EMPLOYMENT in chronological order, giving exact dates where possible.

Dates
From - To / Name of Firm or
Organisation / Position Held / Reason for Leaving

CANVASSING

Are you known or related to any member of staff or trustee of the iSightCornwall Yes / No

(Further details if appropriate ......

DECLARATION

I understand that the information given on this form is to the best of my knowledge true, and I understand that a false declaration could result in instant dismissal.

Signature of applicant...... Date......

FOR OFFICIAL USE ONLY BELOW THIS POINT

Start date: / Rate of pay:
National Insurance No: / Contracted hours:
Job Title: / Leaving date:
Contract date: / P45 Code No:

BANK DETAILS

Bank name & branch:
Name of account:
Account No: / Sorting Code: