MJ Residential Application Form

MJ Residential Services, Lodestone Suite, Creech Castle, Bathpool, Taunton, TA1 2DX

You must complete all sections of the Application Form in blank ink or electronically. We will use this form to help us decide on your suitability for the post so please make sure it is accurate and complete. Curriculum Vitae will not be accepted.

Position applied for*

Closing date*

Date

Where did you first learn of this vacancy?*

Personal Details and Contact Details

Name*

TitleForenames (in full)Surname

Please also provide details of any former names if applicable.

Home Address*

Post Code*

Phone Number*

Please enter a valid phone number.

National Insurance No*

E-mail*

example@example.com

All applicants will be asked to provide documentary evidence of their right to work in the UK do you have any restrictions that apply to you? (If yes please give details).

Please provide details of a minimum of two referees who can comment on your suitability for this post. The referee must be a line manager or supervisor. References from relatives or people who only know you as a friend are not acceptable. If you do not wish us to contact a referee prior to inteview, then please tick the appropriate box and use a separate sheet to explain why. If you have not worked previously, then please give details of a school/college/university official.

Referee 1 (current or most recent employer)

Name*

Relationship to applicant*

Address*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Job Title *

Employment Start Date*

Date

Employment End Date*

Date

Overview of duties/responsibilities *

Referee 2

Name*

Relationship To Applicant *

Address*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Job Title*

Employment Start Date*

Date

Employment End Date*

Date

Overview Of Duties/Responsibilities*

Previous Employment (please list all your employment history and continue on an additional sheet if necessary).

	Job Role	Employment Start Date	Employment End Date	Reason For Leaving
Employment
Employment
Employment
Employment
Employment
Employment
Employment

Gaps In Employment *

Membership Of Professional Associations or Statutory Body & Level of Membership/Role/Registration Number (If Applicable)*

Are you subject to any conditions or prohibitions placed on you by any statutory body in the UK? (If yes - please provide details)*

Reasons Applying For This Post - Please give us specific information to support your application to enable us to shortlist. Please evidence how your skills, abilities and knowledge meet the selection criteria.*

Please confirm weather this will be your only employment - If not please provide details including days, hours worker and weather full/part time. *

Have you been subject to a formal disciplinary or are you in the process of an ongoing disciplinary in your current or any previous employment? And have you ever been dismissed from any employment? (If yes please provide details)*

Are you licensed to drive any of the below?*

CarMotorbike

If you are related to anyone in this organisation please provide details (refer to notes below)*

All posts defined as "regulated activity" are subject to an Enhanced DBS check so that any criminal background (including "spent" convictions, bind-over orders or cautions) is disclosed to the organisation. We cannot employ someone to this post without this check. If you are successful in applying for this post we will ask the DBS for a Disclosure.

The position for which you are applying involves contact with vulnerable groups. It is exempt from the Rehabilitation of Offenders Act 1974 and all subsequent amendments (England and Wales For this position you are not entitled to withhold information about police cautions, bind-overs, or any criminal convictions that would otherwise have been considered "spent" under the Act.

Have you ever been convicted of any offence, been bound-over, or given a caution? (See notes Above)*

YesNo

If yes, please give details in the space provided below. The information you provide will be treated confidence.

Are you currently the subject of any police investigations following allegations made against you?*

YesNo

If yes, please give details in the space provided below. The information you provide will be treated in confidence.

I declare that the information I have given on this form is complete and accurate and that: I am not barred or disqualified from working with vulnerable groups, children or young people I am not subject to any sanctions or conditions on my employment imposed by the Independent Safeguarding Authority, Secretary of State or other regulatory body.

Signed*

Print Name*

Date*

Date

I understand that to knowingly give false information or to leave out any relevant information could result in: the withdrawal of any offer of appointment, or my dismissal at any time in the future, and possible criminal prosecution

Signed*

Print Name*

Date*

Date

Availability - Are there any dates when you are not available for interview? Are there any dates of pre-agreed holiday we would need to consider?*

Data Protection Data Protection accordance with the Data Protection Act 1998, this organisation will only use the information given on this application form to determine your suitability for this post and to monitor equal opportunities. We will keep application forms of unsuccessful candidates for six months before being destroyed.

APPLICANTS (this form will not be used as part of any selection process)

Please help insert name of organisation prevent unfair discrimination by answering ALL of the following questions and ticking the appropriate box. This information will be treated in the strictest confidence and only used to enable us to monitor our performance as an equal opportunities employer. It will not be seen or used by anyone involved in selecting candidates for interview.

Post Title*

Post No*

Name*

First name(s)Surname

Date of Birth*

Date

Ethnic Origin/Nationality*

Please quote a number from the list given below*

21 Black and White Caribbean

22 Black and White African

42 Pakistani, British Pakistani

43 Bangladeshi, British Bangladeshi

44 Other Asian, British Asian

63 Other Black or Black British

99 Prefer Not to Say

Religion (Please tick one box only) Categories determined by office of population Census and Surveys.*

Disability: The Disability Discrimination Act defines disability as a physical or mental impairment which has a substantial and long term adverse effect on his/her ability to carry out normal day to day activities.

Do you consider yourself to be disabled?

If Yes what is the nature of your disability? If you are disabled are there any arrangements we can make for you at interview (E.g. Ground Floor venue, hearing loop, sign language, audio or other adjustments) Please detail requirements?

We will interview all disabled applicants who meet the minimum (i.e. essential) criteria for a post vacancy and consider them on their skills and experience. Please sign here if you are happy for your details to be passed to the interviewing manager so that you can be considered under the two ticks scheme.

Signature*

Print name in full*

It would also help us to know any barriers you have faced when dealing with us and we would be grateful if you would also use this space to make suggestions on how we can improve.*

Type a question

MJ Residential Application Form

EQUAL OPPORTUNITIES MONITORING FORM IS SECTION TO BE COMPLETED BY ALL