PSA Application For Employment

Position Applied For*

Name*

First NameLast Name

Title*

Email Address

example@example.com

Address*

Street Address

Street Address Line 2

City

Postcode

Date Of Birth*

Date

Home Phone Number

Please enter a valid phone number.

Mobile Phone Number*

Please enter a valid phone number.

Current Driving License*

YesNo

Details of Endorsements*

Education History*

School/Colleges & Qualifications Gained

Employment History*

School/Colleges & Qualifications Gained

Reference 1*

Please note here the names and addresses and contact details of one persons from whom we may obtain both character and work experience references.

Reference 2*

Please note here the names and addresses and contact details of one persons from whom we may obtain both character and work experience references.

Other Employment*

Please note any other employment you would continue with if you were to be successful in obtaining this position.

Leisure*

Please note here your leisure interests, sports and hobbies, other pastimes, etc.

Criminal Records*

Please note any criminal convictions except those “spent” under the Rehabilitation of Offenders Act. 1974. If none please state.

Health Details - Do you have any disabilities*

YesNo

Disability

Please give details and specify any special needs in relation to your disability.

General Health

Please list any diseased, disorders, allergies, muscular or muscular skeletal injuries from which you have suffered or do suffer.

Medication*

Please detail any form of medicine, drugs or treatment you are currently and/or regularly receiving.

Absences*

Please list all absences from work in the past 12 months and the reasons for such absences.

Signature*

1. I confirm that the above information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered. 2. I agree that the organization reserves the right to require me to undergo a medical examination. (Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor)

Date Signed*

Date