Your employment application

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1 About us Your employment application The Midcounties Co-operative is an innovative community business. We trade in food retail, travel, funerals, childcare, energy, pharmacy and post offices and we have IT and support service teams. We are proud to be a successful co-operative, owned by our members and founded on the co-operative values and principles. About you Title (Mr, Mrs etc) Forename(s) Home address Surname Preferred name Tel number (daytime) Tel number (mobile) Tel number (evening) National Insurance About the position you are applying for We believe in giving colleagues the opportunity to be more flexible in their working patterns and it would help us if you are also willing to be flexible, as far as possible, with the hours you work. Please complete your preferences below. Position applied for Location Group How many hours would you like to work each week? Minimum hours Maximum hours Could you work additional hours if required? Y N Could you change your hours/days at short notice? Y N Please indicate the earliest start times and latest finish times you could work on each day of the week: DAY Sunday Monday Tuesday Wednesday Thursday Friday Saturday Earliest Start Latest Finish If there is no position available at the site you ve applied to, would you be prepared to consider other sites? If yes, there please is no position indicate how available far you at would the site be you ve prepared applied to travel to, would (time or you distance) be prepared to consider other sites? If yes, please indicate how far you would be prepared to travel (time or distance)

2 Your education, skills and training Qualifications (including GCSEs, O Levels, A Levels, NVQs, degrees and professional qualifications or equivalent overseas qualifications) Subjects Grade Gained within the last 5 years? (please tick) Please use this space to outline other achievements, experience and skills that you feel support your application. This could include courses you ve taken, voluntary work, fundraising, hobbies, IT skills. Please also tell us if there are any foreign languages you can speak. Where you have worked before Please tell us about your employment history, beginning with the most recent. Continue on a separate sheet if necessary. If your application is successful and you accept our offer of employment, it is our policy to contact your last two employers for references. If you do not have an employment history please complete the References section later on in the application form. Date from (mm/yyyy) Employer s name Full address Main duties Reason for leaving to (mm/yyyy) Job title Date from (mm/yyyy) Employer s name Full address Main duties Reason for leaving to (mm/yyyy) Job title Date from (mm/yyyy) Employer s name Full address Main duties Reason for leaving to (mm/yyyy) Job title

3 Please give details of how you spent your time during any gaps in your employment history (including dates): Do you intend to remain employed by your current employer? Y N If yes, how many hours per week do you intend to work with them? If no, how much notice are you required to give? Current salary Have you ever been dismissed by a former employer? Y N If yes, please give details: Have you previously been employed by The Midcounties Co-operative or any other co-operative society? Y N Date from (mm/yyyy) to (mm/yyyy) Where employed Position If you are successful in selection do you have any particular requirements that we need to be aware of for the purpose of the interview? Right to Work in the UK To comply with legislation you are required to take to the interview original proof and a copy of your Right to Work in the UK evidence. No-one is allowed to commence employment with Midcounties Co-operative without this evidence. For UK, EEA and Swiss nationals: Passport or national identity card or if you do not have a passport Full birth certificate (with the name of at least one parent) and evidence of a permanent NI number with proof of change of name (e.g. marriage certificate) if applicable. NB - Accession states A2 proof of right to work in the UK without restriction (exempt from the requirement to obtain an Accession Worker card) e.g. Registration certificate. Non EEA Nationals Current evidence of your right to remain in the UK and of your right to work. There may be a requirement to produce evidence on an annual basis if your leave to remain and work is not indefinite. All applicants please confirm below that you can provide evidence of your right to work in the UK and the type of documents you can provide. I can provide evidence of my Right to Work in the UK. Y N The documents I can provide are: Criminal Offences Have you been convicted of a criminal offence that is not regarded as spent under the Rehabilitation of Offenders Act 1974? Y N If yes, please give details and dates Are any prosecutions pending? Y N For certain roles within the Society you may be required to undertake a Criminal Records Bureau (CRB) check or similar, and in some circumstances an offer of employment will be conditional upon receipt of satisfactory background checks. Driving Do you hold a full UK driving licence? Y N Do you have your own transport for work purposes? Y N Do you have any endorsements (current or pending)? Y N If yes, please give details:

4 Equal opportunities monitoring The Midcounties Co-operative is committed to being an equal opportunites employer and to promoting diversity within the workplace. Completion of the following will assist us in monitoring the effectiveness of our policy. The information you provide will not be used in the selection process, will be treated in confidence and used for statistical analysis only. By signing this form you are giving your consent for us to use the data in this way. Male Female Date of birth Age Marital status Ethnic origin Choose ONE section from A to E, then tick one box to best describe your ethnic group or background. A White British Irish Gypsy or Irish Traveller Any other White background, please give details D Black / African / Caribbean / Black British African Caribbean Any other Black / African / Caribbean background, please give details B Mixed / multiple ethnic groups White and Black Caribbean White and Black African White and Asian Any other Mixed/multiple ethnic background, please give details E Other ethnic group Arab Any other ethnic group, please give details C Asian/Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background, please give details Disability/medical conditions The Society seeks to offer employment opportunities irrespective of physical or mental disabilities wherever possible and will make reasonable adjustments as appropriate. Do you consider yourself to have a disability/medical condition which is relevant to the job for which you are applying? Y N If Yes please give brief details of the effects of the disability/medical condition and any assistance you may need. Please gum down after completion

5 New colleague details This section to be completed by all new colleagues prior to commencement of employment Bank/Building Society account details Account no (8 digits) Sort code (6 digits) Roll no (if applicable) Bank name Bank address The Midcounties Co-operative Name account held in Account holder s signature THIS ACCOUNT MUST BE HELD IN YOUR NAME Emergency contact details Name Address Tel no (daytime) Tel no (work) Tel no (mobile) Relationship References If you do not have an employment history please provide contact information for two personal referees below. These should not be family members. Contact name Address Phone number Relationship Contact name Address Phone number Relationship Values in Action

6 Your declaration I confirm that the information given on this application form is correct to the best of my knowledge, and I understand that if it is shown to be false this could lead to termination of my employment. I understand that any employment with The Midcounties Co-operative is subject to successful completion of a probationary period, receipt of satisfactory references and checks, evidence of eligibility to work in the UK, attending a Welcome to Team Midcounties session and a medical assessment (if appropriate). Signature Date Please ensure you complete the Equal Opportunities Monitoring section and seal, prior to sending this application to the Society. If you would like help with any part of the application process, please call us on Thank you for applying to The Midcounties Co-operative. If you do not hear from us within 6 weeks, please assume your application has been unsuccessful. If you haven t already done so, please visit our website, to find out more about our co-operative values and principles, the different parts of our business, our achievements and why we re proud of what we do. Once you have completed this form please send it to: Recruitment, Personnel Services Group,The Midcounties Co-operative, Co-operative House, Warwick Technology Park, Gallows Hill, Warwick, CV34 6DA Please ensure you use the correct postage when returning. For confirmation of receipt of your application form please enclose a stamped addressed envelope with this form. Recruiter s use only To prevent delays please ensure that the Recruiter s use only and new colleague details sections are completed in full prior to returning to Personnel Administration at the above address. Manager s name Signature Date Provisional Welcome to Team Midcounties Job Title Proposed Start Date Group Site name Site Number Rate of pay (annual/hourly) [delete as appropriate] Perm Casual Temp Length of contract Additional benefits (i.e essential car user) Right to work signed copy of documents attached Y P45 from previous employer attached Y N n/a N Hours Hours and days of work Sunday Monday Tuesday Wednesday Thursday Friday Saturday Start time Finish time Refer a friend scheme Introducer name Group Site Personnel no