Forenames
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Surname
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Address
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Postcode
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Phone
*
Email
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If referral, please provide name of staff member
Expiry date on licence
Licence number
Please detail any other employment you would continue if you were successful in obtaining this position?
Previous employer 1
*
Start date
*
End date
*
Previous position 2
Previous employer 2
Start date
End date
Evidence to Support Criteria in Personal Specification - please refer to the person specification in the job description and explain how you meet each criteria in full – failure to do this will result in your application not going any further.
*
Education, Relevant Qualifications & Dates
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Is there any reason why you cannot be placed in a position working within Regulated Activity?
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No Yes
If YES, please give details
Have you ever been convicted in a Court of Law and/or cautioned in respect of any offence?
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No Yes
If YES, please give details
Health Details
Do you have a physical or mental impairment which has a substantial and long term effect on your ability to carry out day to day activities?
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No Yes
Please specify any special arrangements for work associated with any impairment
Please specify any special arrangements you will need to attend an interview
Please list any diseases, disorders, allergies, muscular or musculoskeletal injuries from which you have suffered or do suffer
Please detail any form of medicine, drugs or treatment you are currently and/or regularly receiving
Please list all absences from work in the past 12 months and the reasons for such absences
Please provide vaccination dates? (proof of vaccination will be required at interview)
Signed
*
Date
*
Other
Disability
Do you consider yourself to have a disability
Yes No
if yes, which of the following descriptions best describes your disability?
If you have a combination of above or other physical or medical conditions ~ please specify
Email
If you are human, leave this field blank.