APPLICATION FOR EMPLOYMENT Medequip Assistive Technology Ltd Is committed to equal opportunities in employment and positively welcome your application irrespective of your gender, race, disability, colour, ethic or national origin, nationality, sexuality, gender identity, marital status, responsibility for dependants, religion, trade union activity or age. Position Applied For Full Name Please Carefully Read The Application Form And The Following Notes, Before You Complete It. If you wish to apply for a job with our company, you must complete this form. The information you give will be treated in confidence and will be seen only by persons employed by the company who need to use it, in the course of their work. The information is asked for because:- It helps the company in deciding whether to take your application further It will be used as the basis for your employment records should your application is successful and you join the company. Notes on Completion Please complete all sections of the form in ink. The form must be completed in English and in your own handwriting. However, if this is not possible (e.g. because of permanent or temporary disablement or because you have difficulty in writing English), another person may help you, but you must ensure that you fully understand the requirements set out on this page and that the person helping attaches a note explaining why you could not complete the form yourself. Please complete all sections on this form fully. If any section does not apply to you, enter not applicable (N/A). This form is available in large print, Braille or audio tape on request. Make sure you sign the form and any additional information you provide. Conditions of Application and Employment When you sign this form you accept that employment with the company is subject to the following conditions:- At least two (2) acceptable references are obtained from your current and previous employers and in certain cases, credit and police checks. Unless you agree otherwise, the company will not contact your current employer until after you have accepted an offer of employment. You supply medical evidence and evidence of competence (e.g. driving licence) as required by the company at any time during your employment. You must be prepared to work overtime and / or change shift and / or transfer to other jobs as necessary to meet the operational needs of the company. You must remain eligible to work in the UK to continue your employment with Medequip. MEDEQUIP APPLICATION FOR EMPLOYMENT
PERSONAL DETAILS Title Last Name First Name Former Name(s) Present Address Postcode Telephone Number Email Address How long have you lived at your present address? years months Previous Address (If less than 5 years at present address) Postcode How long did you live at this address? years months ARRANGEMENTS FOR INTERVIEW If invited to interview are there any special arrangements need in order to facilitate your attendance? If you answered, please specify. e.g. ground floor venue, sign language interpreter, audio tapes, etc. 02
DRIVING DETAILS *must be completed when applying for a driving role Do you have a current FULL Driving Licence for a manual transmission vehicle in category C? How long have you held your Licence for? years months If you have you had any endorsements in the last 4 years please list them Have you had any convictions in the last 10 years for driving whilst under the influence of alcohol/ drugs? If, please enter the Date of Conviction Duration of ban years months Details of Driving Offence(s) Please list all accidents in the past 5 years. Accident Date Accident Details CONVICTIONS All employees will undertake a full enhanced Disclosure and Barring Service (DBS) check as part of their application of employment. Please tick the relevant statement: I declare that I am not on List 99, Protection of Children s Act List (PoCA), and Protection of Vulnerable Adults List (PoVA) or disqualified from working with children, or subject to sanctions imposed by other regulatory body signed: MEDEQUIP APPLICATION FOR EMPLOYMENT 03
I have no convictions, cautions or bind over s. signed: WORK PERMIT Are you permitted to work in the UK? LANGUAGES SPOKEN Please tell us the languages you speak either fluently or have an understanding of: e.g. Fluent in English e.g. Fluent in French e.g. Understanding of Chinese EDUCATION & QUALIFICATIONS Please provide details of all relevant qualifications held. (e.g. GCSE / GCE, O LEVELS, A LEVELS, NVQ, BTEC, CITY & GUILDS, RSA, HNC / HND, DEGREE) School / College / University Subject Studied Qualification and Grade Please list all course(s), training you have undertaken which are relevant for the role you are applying for: Course Title Date Attended Affiliations 04
Please indicate membership of all organisations relevant to the role you are applying for. Name of Organisation Type of Membership Date of Membership EMPLOYMENT Please provide details of your Current or Most Recent Employer Job Title Employer Line Manager Title Employers Address Date Started Date Left (If applicable) Reason for Leaving (If applicable) Please provide details of your employment history. Complete the following section in date order starting with most recent. You must also account for any gaps in your employment history. Date From Date To Job Title Employer Employers Address Reason for Leaving (or details of gap in employment) MEDEQUIP APPLICATION FOR EMPLOYMENT 05
REFERENCES Please give the names and addresses of 2 referees at least one of whom must be a previous employer. Referee Name Company Address Telephone Number Email Address Referee Name Company Address Telephone Number Email Address DATA PROTECTION ACT 1998 Consent and Certification of Details DECLARATION TO BE SIGNED BY ALL APPLICANTS This information detailed in the application form may be used by Medequip in the monitoring and progression of employment policies and practices and in particular Equal Opportunities in Employment Policy. This monitoring is for statistical purposes only and you will not be identifiable from this process. I understand that should my application be successful, giving incorrect information, or any omission made with the intention of misleading the company, could lead to my dismissal without notice. I accept the company s conditions of employment and confirm to the best of my knowledge all the information given is correct. Signed:... Date: 06