Knockmoyle Lodge application form

Application for Employment

Private & Confidential. Once you complete and submit this form, it will be sent to the HR Manager at Knockmoyle Lodge.
Knockmoyle Lodge

Job Reference No: 1
General Details
Job Type*

Full TimePart TimeBanking
Position you are applying for*
Full Name*

PrefixFore Name(s)Surname
Address*

Address Line 1

Address Line 2

Town/CityCounty

Post Code
National Insurance Number

Telephone Number(s)

Email Address*
Current Driving License?*

YesNo
Expiry Date of License
Are there any restrictions on you taking up employment in the UK?*

YesNo
If Yes please provide details
Are there any restrictions on you taking employment with vulnerable adults?*

YesNo
If Yes please provide details

EDUCATION
Schools/Colleges/Universities*
Schools/Colleges/Universities
Schools/Colleges/Universities
Schools/Colleges/Universities
Any other training
EMPLOYMENT

(please start with most recent employment )
If there are any gaps in your employment history please state below the reasons for this? *
Current membership of professional bodies
LEISURE
Please note here your leisure interests, sports and hobbies, other pastimes etc. *
GENERAL COMMENTS
Please give details on how your previous education and work or life experience would be applied to this position. Please also state your reasons for applying and any other strengths you would bring to the role. *

Criminal Records Check
Because of the nature of the work for which you are applying, this post is exempt from the provision of Section 5(2) of Rehabilitation of Offenders (Northern Ireland) Order 1978, by virtue of The Rehabilitation of Offenders (Exceptions) Order (Northern Ireland) 1979, this means that all spent convictions must be disclosed and will be taken into account in deciding whether to make an appointment. Having a criminal record will not necessarily bar an applicant from working for us.

Due to the job in which you are applying for you are required to submit an Enhanced Barred List check which will be carried out by Access NI. All information received will be kept strictly confidential.
Do you consent to us obtaining all necessary information in connection with this application for employment?*

YesNo
Have you ever been convicted of a criminal offence?*

YesNo
If yes please give details of this.

References

Please provide names and addresses of 2 referees, both of which must be your current and second most recent employer and who are not related to you, who we can approach for a confidential assessment of your suitability for this job. If no prior employment, alternative referees can be listed.
Referee 1*
Referee 2*
If for any reason you would prefer we did not approach a previous employer for a reference please tick here.
Because this position involves providing care to vulnerable adults your employment with us is depending on the following:-
- An Enhanced with Barred List check Disclosure being returned and accepted by the company.
- Proof of identity including – Birth Certificate, Passport or driving licence, NI number and a utility bill that has been dated within the past 3 months.
- Two satisfactory written references.
- An accepted explanation for any gaps in your employment.
- Two passport pictures of yourself
- Evidence of physical or mental suitability for your work
Declaration by Applicant

I confirm that all of the information I have provided is correct.

I understand that any false information or deliberate omissions disqualify me from employment or may render me liable to dismissal.
Signature
Date

DayMonthYear
Date

1. Have you had, or do you suffer from any of the following? (Please tick as appropriate) *

	Yes	No	If Yes please give details
Epilepsy
Tuberculosis, Measles, Mumps or Rubella
Rheumatic Fever
Disabling Headache
Fainting Attacks
Diabetes
Kidney Infections
Asthma
Postural Deformity (e.g flat feet, back trouble, sclerosis, inability to bend knees)
Drug Addiction
Mental illness
Hearing Defects
Sight Defects
Are you physically fit for all manual handling tasks, if no please give details
Have you been vaccinated/immunised in the past 5 years, if yes please state what for

2. What other previous illness or injury have you had? (If any operations, please give details.)
5. Names & Address of Family Doctor *
I declare that, to the best of my knowledge and belief, the answers I have given are true.
Signature
Date

MonthDayYear
Date

Application for Employment