Applications

Name*

Prefix First Last

Gender*

Place of Birth*

Town

Country*

Phone*

Mobile or landline

Email*

Current Address*

Street Address Address Line 2 City County Postal Code

Lived at this address since*

DO YOU REQUIRE A WORK PERMIT TO WORK IN THE UNITED KINGDOM?*

Yes

DO YOU HAVE A WORK PERMIT?*

Yes

PLEASE ATTACH A COPY TO APPLICATION FORM*

Max. file size: 125 MB.

Are you a registered member of NISCC?*

Yes

Registration number*

DO YOU HOLD A CURRENT DRIVING LICENCE?*

Yes

Driving number*

PLEASE TICK BOX IF YOU HAVE D1 CLASSIFICATION?

Yes

Are you willing and medically fit to drive company vehicles including minibuses?*

Yes

Education – GCSE, O’Level, A’Level, NVQ*

Subjects passed

Level Attained

Grade

Year

Further Education

Degree/Diploma/Certificate

Result & Date Obtained

Exams to be taken

Professional Qualifications (e.g. Nursing, Allied Health Professional, Social Care, Administration, Management)

Name of Professional Body

Part No. with Date & Result

Final with Date & Result

NMC Registration/Enrolment No./Pin No

Expiry Date

Exams to be taken

EMPLOYMENT HISTORY – PRESENT POST

Employer Name*

Period of Notice*

Salary/Wage*

Job Dept/Location*

Start Date*

Job Title*

Reason for Leaving*

Employer Address*

Principal Duties of Present Post*

EMPLOYMENT HISTORY – PAST

Please list all your previous posts beginning with the most recent including periods out of employment and any training*

Name and Address of Employer

From dd/mm/yyyy

To dd/mm/yyyy

Reason for Leaving

Position/Grade and duties

Please include any other information which may be relevant to this application, detailing how you meet each of the criteria as outlined in the personnel specification*

CONVICTIONS/OFFENCES

Under the Rehabilitation of Offenders (Exceptions) Order Northern Ireland, 1979, Mainstay DRP is included on the list of excepted employers. As such, all criminal conviction may never be regarded as spent and must be disclosed when applying for a post. Therefore it is necessary we ask the following questions:

Have you ever been convicted of any criminal offence?*

Yes

Are you currently the subject of police investigation or do You have any prosecutions pending?*

Yes

List below details of ALL charges, prosecutions, convictions, cautions, bind-over orders – even if they happened a long time ago. You must include any minor matters, any road traffic or motoring offences which may be pending

Please note that disclosure of a conviction does not necessarily debar any applicant from obtaining employment

Have you been the subject of any investigation or enquiry into abuse or other inappropriate behaviour?*

Yes

Do you have or are subject to any disciplinary action? (This can be spent or pending)*

Yes

Please give details*

DISABILITY

The Disability Discrimination Act (DDA) defines a disabled person as someone who has a physical or mental impairment that has a substantial and long term effect on his or her ability to carry out normal day to day activities.* Substantial means neither minor or trivial • Long term means that the effect of the impairment has lasted or is likely last for at least 12 months • Normal day to day activity must affect one of the ‘capacities’ listed in the Act which include mobility, manual dexterity, speech, hearing, seeing and memory.

Do you consider yourself to have a disability, either physical or mental?*

Yes

If yes, please give details

Please give as much detail as possible of your immunisation history e.g. tetanus, MMR, Hepatitis, flu and swine flu vaccinations

If yes, to the above questions, is there anything we need to know about your disability in order to ensure you have equality of opportunity e.g. interpreter, access to car parking facilities, etc?

PERSONAL DECLARATION

I declare that all the foregoing statements are true, complete and accurate.
I understand that if I give wrong information or leave out important information I could be dismissed if I take up this job.
I understand that to take up this job I must have satisfactory references, health assessment and Access NI clearance.
I understand that before taking this job I will have to submit to formal identification a copy of long birth certificate and evidence of qualifications.
I confirm that as far as I know the information I have submitted on this form regarding my medical history and my ability to carry out this job are true, complete and accurate.
I agree to the organisation making any necessary enquiries during the recruitment and selection process for this job.
I understand that canvassing will disqualify me from the selection process for this job.

How did you hear about this vacancy?

If you have been referred by one of our current employees, provide their name below

Job Applications

EMPLOYMENT HISTORY – PRESENT POST

EMPLOYMENT HISTORY – PAST

CONVICTIONS/OFFENCES

DISABILITY

PERSONAL DECLARATION