Personal Information

Your Name (required)

Your Email (required)

Date of Birth (required)

National Insurance Number (required)

Address (required)

Home Phone number

Mobile

Emergency Contact Details (required)

Disability Details: Do you have a physical or mental disability or condition that has a substantial and long term effect on your ability to carry out normal day to day activities?

YesNo

If yes please provide full details

Have you found any tasks difficult during any of your employment history?

YesNo

EDUCATION AND PROFESSIONAL QUALIFICATIONS

Please provide full details of your education history

Current Studies

TRAINING RECEIVED
Please provide full details of training you have undertaken

EMPLOYMENT HISTORY

Current Employer

Name

Address

Telephone Number

Position Held

Start Date

Salary

Other Payments

Contact Name for Reference (including Job Title)

Reason for leaving

Please can you tell us the same information for any previous employment that you feel is relevant.

Questions

Have you been dismissed, suspended or asked to resign from any position?
YesNo

Have you been given a verbal or written warning as part of disciplinary proceedings?
YesNo

Have you been charged with any offence or been investigated by the police?
YesNo

If you have answered yes to any of the above questions please provide the full details

If you have any breaks in employment, please provide full details of these periods and your activities during these times, e.g. unemployed, raising family, voluntary work, illness etc.

ELIGIBILITY TO WORK IN THE UK

The Asylum and Immigration Act 1996 requires all employers to make basic document checks on every person they intend to employ. Should you be shortlisted to attend an interview, you will be required to bring with you documentary evidence confirming your eligibility to work in the UK. An EU or UK Passport will suffice or a UK Birth Certificate or other document issued by the Home Office indicating you may work/stay in the UK, together with a document showing your National Insurance Number i.e. P45, P60 or National Insurance Card. Should you have any queries regarding this matter please contact Karl Sturtridge tel 01872 555755.

Passport Held

Other

Passport Number:

MISCELLANEOUS

Do you hold a valid UK driving licence?

Please specify / full/

Do you have any endorsements on your driver's licence? If so please give full details

Do you have access to a vehicle that you can use for work purposes?
YesNo

If no, are you able to travel for work purposes by another means of transport
YesNo

If yes please specify

Date you can take up employment

If offered this position will you continue to work in any other establishment?
YesNo

If yes, how many hours per week?

Please state briefly why you are applying for this position and outline the experience, skills and other relevant information that make you a suitable candidate for the role

We operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of our Patients. Two satisfactory written references will be obtained before appointing a member of staff and any gaps in employment records are explored. Job offers are confirmed following completion of criminal record/police check.
Criminal Record checks are not applied for until a job offer has been made unless you agree to this in advance.
References will be applied for prior to interview being arranged. If you do not wish us to approach your current employer before interview please tick "No"
All staff are employed on a thirteen-week trial period.
YesNo

Declaration

I confirm that the above information is correct and understand that any misleading statement or intentional omission(s) may lead to my subsequent dismissal, if employed. (Applicants should note that any job offer made will be subject to satisfactory references, satisfactory police check and the satisfactory completion of a probationary period.)
I agree, by virtue of signing this application form agreement, to Peninsula Ultrasound Ltd processing such information as may be necessary for the proper administration of the employment relationship, before, during and after employment provided that proper regard is given to such data protection principles as may be in force.
I understand and accept that Peninsula Ultrasound Ltd may need, on occasion, to divulge information to third parties in accordance with its Data Protection Notification, such information would include references about my employment.
YesNo