Application Form

Application Form
Staywell is the working name for Age Concern Kingston upon Thames
(Charity no. 299988 Company no. 2272550)

An equal opportunities employer
Title of role applied for*
If relevant to the post applied for, please indicate whether you would wish to work:

Full timePart-time
Guidance on completing this application form

It is important that you fill in this form accurately and thoroughly to give yourself the best chance of being invited for interview.
- Refer to the accompanying guidance notes
- Complete all sections
- Sign the form
Contact Details
Name*

InitialsLast Name
Email
example@example.com
Address*

Street Address

Street Address Line 2

Postal TownCounty

Postal / Zip Code

Other Details
How did you hear about this job?*
How much notice do you have to give in your current job?*
Do you hold a valid UK driving licence?*

YesNo
Do you have your own transport for use at work?*

Car/vanMotorcycleCycleNo transport
Do you need a work permit?*

YesNo
Health

In the event of an offer of employment being made, you will be required to submit a completed medical questionnaire. Staywell reserves the right, where necessary, to ask for a medical examination at its expense. Offers of employment will be subject to Staywell being satisfied with the content of the medical questionnaire or the findings of a medical referral.
How many days off work have you had in the last 12 months due to sickness?*
Disability

We want to increase the opportunities for people with disabilities to work with us.
If you have a disability, please tell us if there are any reasonable adjustments we can make to help you do this job.
Disclosure of Criminal Records

In the event of a successful application, if the job involves working with people who are vulnerable or at risk or involves the provision of personal care, Staywell will ask you to undertake Disclosure of Criminal Records. The existence of a criminal record is not necessarily a bar to obtaining a position.
Your application will be rejected if you make any attempt to canvas a member of the Board of Trustees of Staywell, directly or indirectly.

Some information provided by you on this form may be held on a computer system and will be subject to the constraints of the Data Protection Act.

A person specification is provided for the job, which gives you information on the skills, abilities and experience we are looking for. The selection panel will judge your suitability for the post on how well you meet the person specification. Please outline how you meet the criteria. Add anything else about yourself that you feel may be relevant to this position.
Please explain how you meet the criteria for experience*
Please explain how you meet the criteria for aptitude/behaviour*
Please explain how you meet the criteria for skills and abilities *
Please explain how you meet the criteria for knowledge and awareness*
Please detail any relevant qualifications (you do not need to complete this section if attaching a CV - see below)
Please explain how you meet the criteria for other desirable requirements (if relevant)
Employment

Please give details of your previous employment, starting with your present or most recent job. If you have recently left education, give details of any part-time, holiday jobs or work experience.

Alternatively you may attach a CV containing these detail (see below).

Employment History

	Date from	Date to	Employer's name and address	Your role	Your salary when you left the job	Your reason for leaving
1
2
3
4
5
6

Please give details of your education and qualifications. List all periods of study in date order, starting with the most recent. Include details of any professional qualifications or membership of professional bodies.

Alternatively you may attach a CV containing these details (see below).

Education history

	Date from	Date to	Name and address of school, college, university	Name of course - please state full or part-time and give qualifications obtained, including grades
1
2
3
4
5

Attach CV here (optional)

Cancelof

References

Staywell’s normal policy is to take up references after a conditional offer of employment is made. Please give details of two referees, one of whom should be your present or most recent employer and the other, if possible, another employer or someone who knows you in a professional capacity.
Referee 1
Name and address*
Phone number*
Email address
How do you know them?*
Referee 2
Name and Address*
Phone number*
Email address
How do you know them?*
Declaration

The information given on this form is correct. I understand that if I state something which I know is wrong or misleading, or I do not give information which is relevant to my application, my application may be rejected, or, if I get the job, disciplinary action, including dismissal, may result.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Application Form

Guidance on completing this application form

Contact Details

Other Details

Health

Employment

References

Referee 1

Referee 2

Declaration