Application for employment with (Your Company Name)

We are concerned that should we call you to interview, the interviewer is able to make the best use of the time
available. For this reason please help us by filling in all the questions and add any further information you
think relevant.

Please complete the form legibly in black ink or type.

PERSONAL PARTICULARS
Surname Mr/Mrs/Miss/Ms Forenames

Address Previous Surnames

Date of Birth

Place of Birth

Town (if known)

Post Code
Country
Name of Next of Kin
Telephone:
Home Business
Relationship to Yourself

In cases of emergency please contact:

Full Name Number Your Nationality at Present

Have you ever been convicted of any offence by any court, or is there any Have you a current driving licence?
case pending? (This does not relate to convictions regarded as spent by Yes No
virtue of the Rehabilitation of the Offenders Act 1974).
If yes, please specify. Which pension scheme are you
contributing to now?

Are you related to anyone presently working in CMS? National Insurance No

If so, please specify who?
Advertisement Source. Where did
Membership of professional associations see this position advertised?

EQUAL OPPORTUNITIES POLICY

In order to help monitor the effectiveness of this policy and for no other reason, would you please complete the
questions below.

1. How would you describe your ethnic origin? (please tick)

Afro Carribean Asian (Indian) Asian (Oriental)

European (UK/Eire) European (Other) Other

2. Are you a registered disabled person?

Yes No

If yes, what is your registered disabled person’s number? _____________________________________

EDUCATION AND QUALIFICATIONS

 Dates Secondary School, College Examinations taken or to be taken Pass or Fail
From To or University and qualifications gained with dates (with grades)

RELEVANT TRAINING COURSES INCLUDING COMPANY TRAINING

Dates College or Organisation Course Title

From To

PRESENT EMPLOYER

Name and address of employer Position held

Date of Appointment Period of notice required

Present Salary

£ per annum
Nature of Business Other Benefits

Reason for seeking other employment

Brief description of your job/responsibilities

STATEMENT TO PROSPECTIVE EMPLOYEES

Your potential employment with (Your Company Name) will, because of the
nature of our business and the rules agreed within the cleaning industry, be
dependant on the results of a detailed check of your references and background.

We will need to check either for the last ten years, or back to you leaving school
if that was less than ten years ago.

In completing our application form, you must give as much detail as possible of
your previous employment, together with the names of people there and a contact
telephone number if you can. If you were self-employed, the name, address and
telephone number of the accountant who looked after your affairs should be
given.

Should there be any gaps in your employment through changing jobs or not being
employed, you should if possible, give names and addresses of people of
professional standing who have known you personally during those periods, or
details of the Department of Employment office at which you were registered.
The type of people falling into this category would include people such as
Certified Accountants, Doctors, Lawyers, Bankers etc. Should you be unable to
put forward names of people in these types of job, you may give names and
addresses of responsible people who have known you personally for periods not
covered by work references.

You should, in putting forward personal references, seek permission of the

people concerned and make them aware of the fact that they will be asked to
supply a reference.

Criminal Offences

You will also be required to state any criminal proceeding that may have been
taken against you. You can ignore parking fines, however details of any other
offences, including motor offences, must be stated. We would point out that
under the terms of Rehabilitation of Offenders Act 1974, we must ignore offences
which occurred some time ago, and for which the time limits laid down in the Act
have now been exceeded.
 10 YEAR SCREENING
EDUCATION/CAREER HISTORY

Please give as much detail as possible: include contact points, full addresses and telephone
numbers and any periods of unemployment, giving the full address of the Benefit Office(s)
concerned, up to the present date. Self Employment – please give Accountants details.

Full Name and Address of Dates Employed Position Reasons for

Company/ Contact Point/ Please give exact Leaving
Telephone Number (if dates (By Month)
possible)/ Accountants (if
applicable)
Full Name and Address of Dates Employed Position Reasons for
Company/ Contact Point/ Please give exact Leaving
Telephone Number (if dates (By Month)
possible)/ Accountants (if
applicable)
EXPERIENCE AND REASONS FOR THIS APPLICATION

Please give your reasons for making this application, relating your qualifications, experience and personal
attributes to the position for which you are applying. You may also wish to relate your own leisure and spare
time interests.

REFERENCES

The first referee should be your present or last employer. May we take up references without contacting you
beforehand? Yes No

Name Name

Position held by referee Position held by referee

Organisation Organisation
(if appropriate) (if appropriate)
Address Address

Telephone No Telephone No

Please indicate when you would not be available for interview:

I declare that I consider myself to be physically capable of carrying out the duties to which I may be assigned.

If required, I agree to make a Statutory Declaration concerning periods of self employment, employment and
un-employment.

I certify that to the best of my knowledge, the information given on this form is correct and I acknowledge that
misrepresentation of the facts constitutes grounds for immediate dismissal.

Signature: _______________________________________________ Date: _________________________

You will be notified of the result of your application, but this will not be until at least some days after the
closing date. If, additionally, you wish to receive confirmation that this form has been received, please enclose
A STAMPED ADDRESSED ENVELOPE.

Interview Notes

Pay ____________________
Accepted ____________________
Signed ____________________
Date ____________________
Offer: Yes No
 SECURITY SCREENING

Form of Authority
I the undersigned authorise you to contact my school/college, previous
employers, unemployment benefit office and DSS office at Newcastle for
Security Screening purposes.

Name in full ………………………………………………….

Home Address ……………………………………………….

……………………………………………….

……………………………………………….

………………….. Postcode ………………..

NI Number ……………………………………………….

Signed ……………………………………………….

Date ……………………………………………….
YOUR HEALTH

Now that you’ve applied for a job with

(Your Company Name), we need to know a few details
about your health. Please answer as
fully as possible. The information you give
will be treated in strict confidence .

THE JOB

you have applied to join us as a at

ABOUT YOURSELF

Title (Mr, Ms etc.) Your first name Your surname

Your date of birth Your place and country of birth your address

Your height Your weight

Please give your
height without shoes cm/ft kg/lb
and your weight in Do you wear glasses or contact lenses
indoor clothes,
without shoes
---------------------------------------------
no, I don’t yes, I do ---
postcode

DISABILITY

Section One of the Disability Discriminatory Act defines a person as having a disability if he or she has a
physical or mental impairment which has substantial and long-term adverse effect on his or her ability to carry
out normal day to day activities. It is not necessary, therefore, to be registered as a disabled person.

Do you consider you have a disability?

No, I haven’t Yes, I have

Are you currently registered as a disabled person?

No, I am not Yes, I am

Date registered

Please describe the nature of your disability

(Your Company Name) will respect and keep confidential all of the information which you provide it.
However, should any of this information prove to be incorrect you should be aware that it result in us
withdrawing any offer of employment.
YOUR HEALTH
Your health and safety are Answering yes doesn’t If you need to give details
important to us. We need to mean that we can’t of treatment or anything
know if you have, or have had, consider you for the else, please use the space
any of the following conditions. job, and remember that on the back page.
your answers are
confidential.
Have you ever consulted a doctor about any of these?
Hearing Problems
no, I haven’t yes, I have

it was in/since I missed this many days of

work/school
19 I no longer full details are Over years
need treatment on back page
Recurring Headaches or migraine
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page
Back, neck or knee trouble
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page
Wrist, hand or arm strain or injury
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page
Anxiety, stress or depression
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page
A heart complaint or high blood pressure
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page
Recurrent indigestion or a peptic ulcer
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

I no longer full details are
19 Over years
need treatment on back page
Bronchitis, asthma or a chest condition
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page
Blackouts, seizures or epilepsy
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page

A rupture or hernia
 no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page
Diabetes
no, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page

Have you any health problems at the moment?

No, I haven’t yes, I have

details of the problem are

Have you suffered a major illness in the last two years?

No, I haven’t yes, I have

it was in/since I missed this many days of work/school

19 I no longer full details are Over years
need treatment on back page

Are you on any kind of prescribed drugs or medication now?

No, I’m not yes, I am, I have given details on the back page

Have you ever been into hospital or had any operation?

No, I haven’t yes, I have, I have given details on the back page

Have you ever been turned down for a job or medically retired for reasons of health?
No, I haven’t yes, I have, I have given details on the back page

Is there anything you think you should add about your health
No, that’s all yes, there’s this

Your GP’s name the address of your GP’s practice

FURTHER EXPLANATION

The space on this

page is provided
for you to give
detailed answers to
any of the
questions in the
form.

DECLARATION

I declare that to the best of my knowledge, the information I have given on this form is
true and correct. I also understand that I may be dismissed if I’ve given misleading
or false information.

Your signature Date

Thank you for taking the time to fill out this form.