APPLICATION FORM

PRIVATE AND CONFIDENTIAL

PLEASE PRINT CLEARLY

Employment required
Position applied for:
Where did you hear about this vacancy?
When would you be available to start?
If offered this position will you continue to work in any other capacity? Yes/No
If yes state where and in what capacity:

Personal details
Full name: Forename(s) Surname:
Home address

Postcode:
Home telephone: Mobile:
Date of Birth: National Insurance Number:
Are you legally eligible for employment in the UK? Yes/No

Secondary and Further Education

DATES
TYPE OF EXAMINATION
SUBJECTS
SCHOOL RESULTS
FROM - TO

1
Experience
Outline particular experience gained in previous positions or in activities outside of work
that you feel show your aptitudes and skills for the position applied for.

Do you have a relevant current driving licence? Yes/No

Please give details of any previous or pending driving offences:

Please provide details of any accidents in which you have been involved within the last
five years:

Do you require the Use of Corrective Eyewear (Spectacles, Contact Lenses) for any
reason. If so, what was the date of your last Eye Test?

Note: If you are invited to attend an interview, and your driving licence is relevant to
your application, please bring it with you.

Give details of any criminal convictions that you may have (as in accordance with the
Rehabilitation of offenders Act 1974.)

2
Previous Employment
List below past employment, beginning with your most recent.
Name & Address
Of previous employment

Employed From/To
Position held
Salary
Main duties:

Reason for leaving

Name & Address
Of previous employment

Employed From/To
Position held
Salary
Main duties:

Reason for leaving

Name & Address
Of previous employment

Employed From/To
Position held
Salary
Main duties:

Reason for leaving

Name & Address
Of previous employment

Employed From/To
Position held
Salary
Main duties:

Reason for leaving

3
Please describe any other work you have been involved in, eg. Voluntary, freelance,
project work.
Dates/duration Description

Interests
Give details of your main interests and the depth to which these are pursued.

Additional Information
Give any further information which you think may assist us in considering your
application.

References
Please provide names, address and occupations of two referees (not relatives),
preferably previous employers whom we may approach with regard to your application.
Name: Name:
Occupation: Occupation:
Address: Address:

Telephone: Telephone:

I declare that to the best of my knowledge and belief the information given in this
application is correct. I understand that any false or misleading statement or
omission on my part my result in termination of employment:

Signature:_________________________ Date:_________________________

4
Health

Name and Address of your own General Practitioner

Dr

HAVE YOU EVER SUFFERED IF YES: IF YES:

FROM ANY OF THE HOW LONG NAME OF
FOLLOWING? OFF WORK DOCTOR AND
HOSPITAL
Typhoid, Paratyphoid or Enteric YES/NO
fevers?
Food Poisoning? YES/NO
Dysentery? YES/NO
Persistent diarrhoea or infection of YES/NO
the bowels?
Tuberculosis? YES/NO
Tropical disease, eg Hookworm, YES/NO
Bilharia, etc.
Have you suffered from any of the YES/NO
following within the past two
years?
Chronic bronchitis with spit? YES/NO
Diarrhoea and/or vomiting for more YES/NO
than two days?
Skin rash or any skin disease? YES/NO
Recurrent boils/septic fingers? YES/NO
Discharge from Ear? YES/NO
Eye? YES/NO
Nose? YES/NO

Have you ever suffered from back problems? Yes/No

Do you smoke? Yes/No

If yes please give details of how many cigars/cigarettes per day:

TO BE SIGNED BY A MEMBER OF ARNOTTS MANAGEMENT

THIS EMPLOYEE MEETS HEALTH STANDARDS AND THERE ARE NO
FOOD SAFETY ISSUES. CANDIDATE CAN BE FORWARDED FOR
INTERVIEW. SIGNED _________________DATE _____________________

5
 Have you ever had to take time of work with back problems? Yes/No
If so please give full details.

Please give a statement of your general health now and in the past.

Have you lived or been abroad in the past 10 years? No/Yes

If YES: where and when

I declare that all the above statements are true and complete to the best of my
knowledge.
Signed: Date:

Have you suffered an injury for which you have or intend to claim in damages?
Yes/No
If you please give details

Authorised by: Issue Date: 18/01/16 Issue No: 3

6
 CONFIDENTIAL

Self Classification by Employee/Job Applicant

Statement of Religion/Type of School

This form asks you to provide information on your religious affiliation for the
following reasons.

We are fair employers: we do not discriminate on the grounds of religious

belief or political opinion; we practice equality of opportunity in employment.

Most important of all we operate the merit principle i.e. we select the best
man or woman for the job, or promotion/training opportunity.

We want to show we are fair employer; we want to demonstrate clearly and

openly our commitment to equality of opportunity in employment.

To do so we need to monitor the religious affiliation of our employees and job

applicants.

So we are asking you to help us by indication your religious affiliation on the

reverse side of this form.

The information you are asked to supply will be treated in the strictest
confidence and protected from misuse. This information will not be available
to anyone making decisions about you application and will be used for
monitoring purposes only.

7
 COMMISSION FOR RACIAL EQUALITY FOR NORTHERN
IRELAND
MONITORING FORM

The Commission for Racial Equality for Northern Ireland employs a comprehensive
monitoring system as part of its policy as an equal opportunity employer.
For monitoring purposes only, please give the following information, which will be held
separately from your application and will form no part of the recruitment process. The
information you provide is confidential and will not be released unless the Commission is
compelled to do so by statute and/or by court order.
Community background:-
I am a member of the Protestant community
I am a member of the Roman Catholic community
I am a member of neither the Protestant nor
Roman Catholic community
Gender:- Male Female Age:-______________________

Do you consider that you have a disability? Are you registered as disabled?

Yes No Yes No

Your origins:-
Please state your ethnic group ______________________________
OR tick one or more of the following, as appropriate.

African Bangladeshi Chinese Caribbean

Indian Irish Traveller Pakistani

White Mixed Ethnic

Group

Nationality:-

Marital Status:-

Family Status:- No caring responsibilities Care for children

Care for other relatives Other

Where did you see this post advertised? _______________________

Thank you