APPLICATION FORM FOR EMPLOYMENT

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1 APPLICATION FORM FOR EMPLOYMENT Please complete in black ink or type. If you have a disability which makes completing this application form difficult, we will be happy to accept your application in another suitable medium. Applicant No: (office use only) Position applied for: Internal application External application Send to: Langford Veterinary Services Ltd, Langford House, Langford, Bristol, BS40 5DU YOUR DETAILS (Please put in BLOCK CAPITALS and in BLACK ink or type) Title Surname Forenames Name known by Do you have a right to work in the UK? Yes No If you are offered a post you will be required to provide original proof of your right to work in the UK. Please give any dates when you are not available for interview:

2 Telephone home (inc area code) Telephone work (discretion will be applied) Telephone mobile address House name/number Address Postcode NI Number GENERAL EDUCATION AND QUALIFICATIONS Applicants offered a post will be asked to verify their qualifications on appointment. Educational Institution Date From Date To Qualifications Obtained Subject Grade

3 From To Subject Grade Professional Qualifications/ Training Courses From To Qualifications Obtained

4 MEMBERSHIP OF PROFESSIONAL BODIES Body (Bodies) Registration Type e.g. full/provisional CURRENT OR LAST EMPLOYER Job Title Current Salary Name of Employer Address of Employer Post Code Tel No Dates employed from From To Notice Period Reason for leaving

5 Brief summary of duties

6 PREVIOUS EMPLOYMENT HISTORY (Past 5 years, most recent first Please continue on a separate sheet if necessary) Position held & principle duties performed Name & address of employer From To Reason for leaving

7 STATEMENT IN SUPPORT Please outline your experience and achievements and explain why you are suitable for this post. Please continue on a separate sheet if necessary

8 OTHER (Please delete as applicable) Do you hold a current driving licence? Full Provisional No Do you have access to a motor vehicle? Yes No If offered a position, would you continue to work in any other capacity or for another company? Yes No If yes, please give details Have you had any criminal convictions, which are not spent convictions under the Rehabilitation of Offenders Act 1974? Yes No If yes, please state the date(s) of conviction(s) and the nature of the offence(s): Are you facing any criminal prosecutions? Yes No If yes, please state the details below:

9 REFERENCES Please give details of two people able to provide references relating to your experience and suitability to this post. The first referee should be your current or most recent employer (not friends or family). Referee 1 Referee 2 Name Position Address Postcode Tel No address Occupation Capacity in which known to you May we approach if called for interview Yes No Yes No DATA PROTECTION By providing the information contained within this application form, you are consenting to its use for the purpose of processing your application, assessing your performance in the future (should your application be successful) and monitoring the efficiency of our recruitment and other employment procedures. Individuals have the right of access to personal data concerning themselves. Your details may be retained on file for a period of up to 6 months for any suitable vacancies that may arise. Please confirm whether or not you wish us to retain your details for this purpose. Yes No

10 DECLARATION I confirm that the information given in this application is true and complete. I understand that if it is subsequently discovered that any statements are false or misleading, my application will be disqualified or, if employed, may be grounds for dismissal. Signature: Date: DIVERSITY MONITORING Langford Veterinary Services actively supports the principle of Equal Opportunities in employment and is committed to ensuring that individuals are treated fairly, with respect and are valued. The sole criterion for selection or promotion in the company is the suitability of any applicant for the job. In order to allow us to monitor that our policy is working, it would be helpful if you would complete this section. We are aware that you may be hesitant in providing the personal details requested. Please be assured that this information will NOT be used as part of the selection process. It will be detached from your application form upon receipt and will not be seen by anyone involved in the selection of this post. All the information on this sheet will be treated in strictest confidence and stored in accordance with the Data Protection Act for monitoring and reporting purposes only.

11 PERSONAL DETAILS Applicant No: (For office use only) Position applied for: Full-time Part-time How did you become aware of this vacancy? Surname: Forenames: Title: Name known by: Address: Postcode: Telephone (incl area code): NI number: Date of Birth: EQUAL OPPORTUNITIES (Please delete as applicable) Gender: Male Female Do you consider that you have a disability under the Equality Act 2010? Yes No If yes, please specify: If employed, please state any specific requirements or support you will require to carry out your duties: What is your nationality? Ethnic Origin: (please tick) White British White Irish Other White background Black or Black British Caribbean Black or Black British African Other Black background Asian or Asian British Indian Asian or Asian British Pakistani Asian or Asian British Bangladeshi Chinese Other Asian background Mixed White and Black Caribbean Mixed White and Black African Mixed White and Asian Other Mixed background Other Ethnic background Information refused Thank you for assisting Langford Vets to monitor the effectiveness of its Equality and Diversity policy

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