JOB APPLICATION FORM

Please complete this form accurately, giving as many details as possible of your skills and experience
relating to this job application. Shortlisting will be based on the information gathered from this form.
You will only be advised of the outcome if you are selected for the interview process. All applicants who
are required for interview will be notified within 7 days of the closing date.

Please ensure the form is printed out, signed, dated and returned by the closing date to the address given on
the last page. We are unable to accept forms returned as email attachments without a signature.

Please complete this form in black ink and BLOCK CAPITALS.

SECTION 1 : POSITION APPLIED FOR

Job Title

Location

Where did you see this post advertised ?

SECTION 2 : APPLICANT DETAILS

Title Surname First Name

Home address

Postcode

Telephone Numbers : please include full STD code

Home
Work
Mobile ( where possible )

email address ( where possible )

Do you hold a current driving licence ? YES/ NO

Are there any restrictions regarding your employment ?

It will be a condition prior to employment that evidence regarding
eligibility to work in the United Kingdom is provided. ( This evidence YES / NO
could include a birth certificate, P45, P60, National Insurance card or
an appropriate passport). If Yes, please provide further information

How much notice do you need to give your current employer ?

SECTION 3 : EMPLOYMENT RECORD ( PREVIOUS 10 YEARS )

Please start with your most recent employment. Briefly describe the main duties and responsibilities of
your role. If you wish to include additional information please do so in Section 6.

1.Current / most recent employer

Name
Address

Job Title
Period of employment From To
Brief description of duties

Reason for leaving / changing

2. Employer
Name
Address

Job Title
Period of employment From To
Brief description of duties

Reason for leaving / changing

3. Employer
Name
Address

Job Title
Period of employment From To
Brief description of duties

Reason for leaving / changing

4. Employer
Name
Address

Job Title
Period of employment From To
Brief description of duties

Reason for leaving / changing

SECTION 4 : EDUCATION / QUALIFICATIONS

Please detail your education and any qualifications which you feel are relevant to the post. Please start with
the most recent.
( Current courses should also be included )

School / College / Subject studied Qualification / Level Date gained

University / Training
Body
SECTION 5 : TRAINING

Please list any training you have received or courses which did not lead to a qualification but which you
feel are relevant to the post.

Training Course Date

SECTION 6 : EXPERIENCE / SKILLS

This section is for you to give specific information in support of your application and to add additional
information from previous sections.
Please set out the information below and if required continue on a maximum of two sides of A4 paper.
SECTION 7 : REFERENCES

Please give the name, address and position / occupation of two referees. One must be your present or most
recent employer. ( References from friends or relatives are not acceptable ).
References will only be taken up for the successful candidate.

Name
Position
Organisation
Address
Telephone

Name
Position
Organisation
Address
Telephone

SECTION 8 : DECLARATION

I confirm that the above information is true and accurate and that David Roberts & Partners ( Insurance
Brokers ) Ltd are authorized to write to any of the above named for reference and / or conduct a credit
reference ( you will be notified prior to any credit reference being requested ).
I confirm that I have not been convicted ( or awaiting trial ) for any criminal offence and that I have no
County Court Judgements ( CCJ ) outstanding or any debts that are likely to give rise to a CCJ.
I confirm that I have not entered into any agreement ( for example an individual voluntary arrangement )
with creditors or been subject to bankruptcy proceedings.
I confirm that I have never been investigated or dismissed for misconduct or malpractice in relation to any
business activity.

( If you are unable to sign this declaration you should put a line through the relevant text in the declaration,
sign the form and provide full details on a separate piece of A4 paper which you should also sign ).

By signing and returning this application you consent to David Roberts & Partners ( Insurance Brokers )
Ltd using and keeping information about you and provided by you ( or third parties such as referees and
credit reference agencies ) relating to your application and future employment.
If you are unsuccessful this information will be retained for a maximum of 6 months from the closing date
of the application process.

..
Signed Date

Please print and return your completed form to

HR Department, David Roberts & Partners ( Insurance Brokers ) Ltd, Chancery House, Slaidburn Crescent,
Southport PR9 9YF