PULTENEYTOWN PEOPLE’S PROJECT

APPLICATION FOR EMPLOYMENT

Position Applied for Date of Application

Location Source of application (name of newspaper, journal, job centre or

other)

To be completed in applicant’s own handwriting

Surname Name before marriage Place of birth

Date of Birth
Dr/Mr/Mrs/Miss/Ms

Forenames Marital Status

Full Address Do you require a U.K. work permit?

 Yes  No

Do you hold a valid driving licence?

 Yes  No

Are you on the Disabled Persons Register:

Post Code
 Yes  No

If so, please give your Registration Number.

Telephone Number

EQUALITY IN EMPLOYMENT
The policy of Pulteneytown People’s Project is to provide equal opportunity to all members of staff and to ensure that no member of staff or
applicant for employment is disadvantaged by conditions or requirements which cannot be shown to be justified. The promotion of equal
opportunity will be actively pursued through the application of employment policies, which will ensure the individuals receive treatment, which is
fair, equitable and consistent with their skills and abilities. We should be most grateful if you would provide this information to help us monitor the
effectiveness of our equal opportunities policy. I would describe my ethnic or cultural origin as:

Black White

A AFRO-CARIBBEAN C ASIAN E EUROPEAN

B AFRICAN D OTHER* F OTHER*

(Please tick appropriate box)

(*Please specify)
The categories and definitions of ethnic or cultural origins used above are those accepted by the Commission for Racial Equality.

Have you ever been convicted of any offence before a Court of Law? Yes  No 
If ‘Yes’, please give details
Education and Training
Name and Location Examinations Passed or to be Taken
(with grades and names of courses studied)

Schools

Colleges

Other Education
and Training

Please give details of any other specialised training you have undertaken. Membership/Grade of professional institutions

Employment Information
Have you applied for a position with Pulteneytown People’s Project before? If ‘Yes’ please  Yes  No
give details, including dates.

Employment is subject to Disclosure Scotland and satisfactory references being received. In this respect two references are required from previous
employers including your current/most recent employer. We will only contact these referees if we offer you employment .

1. 2.

Present or Last Appointment

Employer’s (name and address) Date employment began Date employment finished

Current or last salary

Employer’s type of business

Positions held

Duties

Period of notice (or date of leaving)

Reason for leaving/ wishing to leave

 Name and address of employer From To Position held Reason for leaving

Please tell us about any attributes /skills that you feel you can bring to this position, or about any voluntary work you may have undertaken

I confirm that the information given on this application form is correct.

Signature: __________________________________ Date:______________________

Medical Questionnaire

1. In general, is your health good?  Yes  No

If no, please give details

2. How many days have you been absent from work/school/college due to
sickness or injury in the last year?

3. Have you consulted a Doctor at any time over the last five years for anything
other than minor illness? (e.g. cold, flu, etc)

4. Are you presently taking any medication? (other than contraceptives?)  Yes  No

5 Are you currently receiving or on a waiting list to receive any medical treatment?  Yes  No
If, ‘Yes’, please give details

6. In the last five years have you suffered from:

Yes No Yes No Yes No
Back Problems   Fainting or dizziness  Severe headaches  

Skin Disorders   Depression/anxiety/stress  Epilepsy / Blackouts or fits  

Stomach upsets   Chest/Respiratory Infections  Vertigo  

Migraine   Gynaecological problems  Heart disorders  

Notice to Applicant

If you answer ‘Yes’ to any of questions 3 – 6 you will not automatically be excluded from employment with Pulteneytown People’s Project. However,
we may investigate your answers further and may require either contact with your G.P. (with your express written permission) for evidence of
satisfactory health. We need to know you are able to carry out the duties as per the job description, taking into account any obligations we have under
the Disability Discrimination Act.

As a condition of Employment you are required to answer the above honestly and to the best of your knowledge and belief. Misrepresentation or
deliberate omission is a dismissible offence under our disciplinary procedure.

This application form will form part of your written statement of particulars of employment, which is your contract of employment with this company.
False or withheld information may lead to termination of employment.

Statement by applicant

I have answered the above questions honestly to the best of my knowledge and belief.

Signature: __________________________________ Date:______________________